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Date | yyyy-mm-dd |
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Doctor's signature |
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1. Patients with either II-degree debrided burn wound or donor site | |
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Patients who replies "No" to any of the above questions will not enter the study | |
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3. Ages between 18~65 years old |
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Patients who replies "Yes" to any of the above questions will not enter the study | |
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Doctor's signature |
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Date | yyyy-mm-dd |
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Other diseases | |
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If yes, please describe |
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History of allergic disease | |
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If yes, please describe |
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If yes, please describe |
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If yes, please describe |
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Start Date |
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Dosage per Day |
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Doctor's signature |
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End Date |
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Date | yyyy-mm-dd |
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Systolic pressure (SP) | mmHg |
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Diastolic pressure (DP) | mmHg |
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Route of Administration |
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Name of Drug |
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Respiratory rate | 次/分 |
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Grouping | |
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Pulse rate | 次/分 |
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Marital status | |
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Date of birth | yyyy-mm-dd |
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Education level |
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Signs and Symptoms | |
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Wound Bed (exudation) | |
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Wound Bed (erythema) | |
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Wound Location |
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Wound Surface Area | cm2 |
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Wound Bed (bleeding) | |
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Wound Type | |
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Uric acid | μmol/L |
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Creatinine | μmol/L |
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Urea nitrogen | mmol/L |
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Serum albumin | g/L |
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Serum bilirubin | μmol/L |
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AST | U/L |
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ALT | U/L |
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Urine protein | g/L （或定性） |
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Urine red cell | 个/μL （或定性） |
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Urine WBC | 个/μL （或定性） |
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PLT | X10*9/L |
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Hb | g/L |
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RBC | X10^12/L |
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WBC | X10*9/L |
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Routine Urinalysis | |
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Liver Function Test | |
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Date of test | yyyy-mm-dd |
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Routine Blood Test | |
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Date of test |
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Date of examination | yyyy-mm-dd |
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Renal Function Test | |
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Date of test | yyyy-mm-dd |