英文回答:
Discharge Summary。
Patient Name: [Patient Name]
Medical Record Number: [Medical Record Number]
Date of Admission: [Date of Admission]
Date of Discharge: [Date of Discharge]
Reason for Admission: [Reason for Admission]
History of Present Illness: [History of Present Illness]
Past Medical History: [Past Medical History]
Social History: [Social History]
Family History: [Family History]
Review of Systems: [Review of Systems]
Physical Examination:
Vital Signs: [Vital Signs]
General: [General]
Head, Eyes, Ears, Nose, and Throat: [Head, Eyes, Ears, Nose, and Throat]
Cardiovascular: [Cardiovascular]
Respiratory: [Respiratory]
Gastrointestinal: [Gastrointestinal]
Genitourinary: [Genitourinary]
Musculoskeletal: [Musculoskeletal]
Neurological: [Neurological]
Laboratory Data: [Laboratory Data]
Imaging Studies: [Imaging Studies]
Procedures: [Procedures]
Medications: [Medications]
Hospital Course: [Hospital Course]
Discharge Diagnosis: [Discharge Diagnosis]
Prognosis: [Prognosis]
Follow-Up Plan: [Follow-Up Plan]
Instructions: [Instructions]
Signature of Attending Physician: [Signature of Attending Physician]
中文回答:
出院证明。
患者姓名, [患者姓名]
病历号, [病历号]
入院日期, [入院日期]
出院日期, [出院日期]
入院原因, [入院原因]
现病史, [现病史]
既往史, [既往史]
社会史, [社会史]
家族史, [家族史]
系统查体, [系统查体]
体格检查:
生命体征, [生命体征]
全身, [全身]
头、眼、耳、鼻、咽, [头、眼、耳、鼻、咽
心血管, [心血管]
呼吸, [呼吸]
消化, [消化]
泌尿, [泌尿]
骨骼肌肉, [骨骼肌肉]
]
神经, [神经]
实验室检查, [实验室检查]
影像学检查, [影像学检查]
诊疗经过, [诊疗经过]
出院诊断, [出院诊断]
预后, [预后]
随访计划, [随访计划]
注意事项, [注意事项]
主治医师签名, [主治医师签名]
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