病历总结模板
病历____ ： 病案号：__________
一、病史特点:
1 、患者___年___性患者，____岁，因”____________________________”______入院；
2、现病史：_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________；
3、既往史：__________________________________________________________________________________________________________________________________；
4、体格检查（重点写阳性体格检查特点）：____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________；
5、目前所有的辅助检查及阳性结果分析；______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________;
6、附相关重要影像图片：
二、目前诊断：“_____________________________________”
三、诊断依据：
● 支持点：
1、______________________________________________________________
_______________;
2、______________________________________________________________
_______________；
3、______________________________________________________________
_______________；
● 不支持点：
1、______________________________________________________________
_______________;
2、______________________________________________________________
_______________；
3、______________________________________________________________
_______________；
四、 鉴别诊断：
1、 “”
鉴别要点： ___________________________________________________________________________________________________________________________________________________________________________________
2、 “”
鉴别要点： ___________________________________________________________________________________________________________________________________________________________________________________
3、 “”
鉴别要点： ___________________________________________________________________________________________________________________________________________________________________________________
五、 诊断思路分析：____________________________________________________
_________________________________________________________________________________________________________________________________________________________________________;
六、 针对目前诊断，现有的治疗手段都有哪些（这里我们不管什么治疗手段，只要是有效的方法，我们都认可，所谓尚武精神的核心就是不分派系、不分中外技术，只要能强身健体的方法就是好方法），这些治疗手段的优点在哪儿？缺点在哪儿？如何取舍？
1、”____________________”
✧ 优势：_______________________________________________________
_________________________;
✧ 不足：_______________________________________________________
_________________________;
✧ 如何取舍：____________________________________________________
____________________________;
2、”____________________”
✧ 优势：_______________________________________________________
_________________________;
✧ 不足：_______________________________________________________
_________________________;
✧ 如何取舍：____________________________________________________
____________________________;
3、”____________________”
✧ 优势：_______________________________________________________
_________________________;
✧ 不足：_______________________________________________________
_________________________;
✧ 如何取舍：____________________________________________________
____________________________;
4、”____________________”
✧ 优势：_______________________________________________________
_________________________;
✧ 不足：_______________________________________________________
_________________________;
✧ 如何取舍：____________________________________________________
____________________________;
七、针对患者目前这一诊断
1、您选择了什么治疗手段 ？_______________________________________该治疗手段的主要目的是：_____________________________________________________________________________________;
2、治疗整体过程描述：_______________________________________________________________________________________________________________________________________________________________________________________________________________;
3、治疗关键步骤描述如手术记录：_______________________________________________________________________________________________________________________________________________________________________________________________________________;
4、关键影像及影像学特点：_______________________________________________________________________________________________________________________________________________________________________________________________________________;
5、适当的解剖回顾：_______________________________________________________________________________________________________________________________________________________________________________________________________________;
八、您认为您所选择的治疗手段的操作要点是：
1、_____________________________________________________________________________;
2、_____________________________________________________________________________；
3、_____________________________________________________________________________；
九、个人小结或术后疗效评定，总结经验，吸取教训。
1、术后疗效评定：
近期疗效_________________________________________________ 远期疗效
2、总结经验：_____________________________________________________________________________；
3、个人小结：______________________________________________________________________；
主管医师：_________________