1. Patient information: record the basic information of the patient, such as name, age, gender, contact information, etc.
2. Service date and time: specify the specific date and time of signing the service.
3. Problem description or disease overview: briefly describe the patient's chief complaint or disease overview, including related symptoms and duration.
4. Doctor's behavior: the result of physical examination or evaluation. Provide a given treatment plan or drug prescription. Give oral consultation and health education guidance. Regular follow-up plan and next appointment arrangement.
5. Patient's feedback and cooperation: record the patient's feedback information on the treatment plan provided by the doctor, whether he understands the use of drugs and whether he can take drugs on time.