How to fill in the medication consultation record form for inpatients and outpatients?

1, patient's name, recorder, outpatient number and medical record number. Monitor inspectors, prescriptions, bed doctors.

2. Record the patient's brief medical history and signs (positive signs and necessary negative signs), examination items, examination results, preliminary diagnosis, drug name, dosage and usage, and treatment opinions.

3. Follow-up medical records focus on the changes of the disease and the diagnosis and treatment effect.