Front sheet, Summary sheet 首页,摘要表

History sheet 病历表

Physical examination sheet 身体检查表

Physician's order sheet 医嘱单

Physician's progress note 医生用病情进展记录

Laboratory reports 检验报告

Radiographic reports X光检查报告

Nursing notes 护理记录

Graphic chart 图式病历

Discharge summary sheet 出院摘要

Operation report 手术报告

Anesthesia record 麻醉记录

Consultation sheet 会诊单

Intake and output sheet 摄取与排泄记录

Consent (or permission) for operation 手术同意书

Emergency room record 急诊室记录

住院病历表

身家调查事项 ( identifying data or biographic data)

admission date 住院日期

hospital number = chart number 病历号码

room number 病房号码

name

sex

age

birth date

birth place

marital status = civil status 婚姻状况

address

occupation

empolyer 雇主公司行号

health insurance number 医疗保险号码

referring physician 转介医生