病历中的主诉 ,是第一项 ,写得是否规范 ,反映整份病历的质量和水平。1　文字应精炼主诉应该写出病人的主要症状和 (或 )体征及其持续时间 ,还应做到文字精炼。不应有多余的字。如“右颌下长一肿物 1周” ,应将“长一”二字去掉。“发热、腹泻已 2天”。此例中“已”是表示时间 The main complaint in the medical record is the first item, which is written standard and reflects the quality and level of the entire medical record. 1 The text should be refined. The chief complaint should write out the patient’s main symptoms and (or) physical signs and their duration. It should also be written. There should be no extra words. For example, if the “lung mass under the right submandibular length is 1 week”, the word “Changyi” should be removed. “Fever and diarrhea have been 2 days.” In this example, “already” means time