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您的位置:医学教育网 > 卫生网校 > 医学英语 > 正文

医学英语——住院文书格式

2009-06-09 17:29 医学教育网
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  1、抗生素医嘱[Antibiotic order]

  Prophylaxis [预防性用药] Duration of oder[用药时间] 24hr

  Procedure[操作,手术]

  Empiric theraphy [经验性治疗]

  Suspected site and organism[怀疑感染的部位和致病菌] 72hr

  Cultures ordered[是否做培养]

  Documented infection[明确感染]

  Site and organism[部位和致病菌] 5days

  Other[其他]

  Explanation required [解释理由] 24hr

  Antibiotic allergies[何种抗生素过敏]

  No known allergy [无已知的过敏]

  Drug+dose+Route+frequency[药名+剂量+途径+次数]

  2、医嘱首页[Admission / transfer]

  Admit / transfer to [收入或转入]

  Resident [住院医师] Attending[主治医师]

  Condition [病情]

  Diagnosis[诊断]

  Diet [饮食]

  Acitivity [活动]

  Vital signs[测生命体征]

  I / O [记进出量]

  Allergies[过敏]

  3、住院病历[case history]

  Identification [病人一般情况]

  Name[性名]

  Sex[性别]

  Age [年龄]

  Marriage[婚姻]

  Person to notify and phone No.[联系人及电话]

  Race[民族]

  I.D.No.[身份证]

  Admission date[入院日期]

  Source of history[病史提供者]

  Reliability of history[可靠程度]

  Medical record No[病历号]

  Business phone No.[工作单位电话]

  Home address and phone No.[家庭住地及电话]

  Chief complaint[主诉]

  History of present illness[现病史]

  Past History[过去史]

  Surgical[外科]

  Medical[内科]

  Medications[用药]

  Allergies[过敏史]

  Social History[社会史]

  Habits[个人习惯]

  Smoking[吸烟]

  Family History[家族史]

  Ob/Gyn History[ 婚姻/生育史]

  Alcohol use[喝酒]

  Review of Aystems[系统回顾]

  General[概况]

  Eyes,Ears,Nose and throat[五官]

  Pulmonary[呼吸]

  Cardiovascular[心血管]

  GI[消化]

  GU[生殖、泌尿系统]

  Musculoskeletal[肌肉骨骼]

  Neurology[神经系统]

  Endocrinology[内分泌系统]

  Lymphatic/Hematologic[淋巴系统/血液系统]

  Physical Exam[体检]

  Vital Signs[生命体征]

  P[脉博]

  Bp[血压]

  R[呼吸]

  T[温度]

  Height[身高]

  Weight[体重]

  General[概况]

  HEENT[五官]

  Neck[颈部]

  Back/Chest[背部/胸部]

  Breast[乳房]

  Heart[心脏]

  Heart rate[心率]

  Heart rhythm[心律]

  Heart Border[心界]

  Murmur[杂音]

  Abdomen[腹部]

  Liver[肝]

  Spleen[脾]

  Rectal[直肠]

  Genitalia[生殖系统]

  Extremities[四肢]

  Neurology[神经系统]

  cranial nerves[颅神经]

  sensation[感觉]

  Motor[运动]

  *Special P.E. on diseased organ system[专科情况]

  *Radiographic Findings[放射]

  *Laboratory Findings[化验]

  *Assessment[初步诊断与诊断依据]

  *Summary[病史小结]

  *Treatment Plan[治疗计划]

  4、输血申请单[Blood bank requisition form]

  (1)reason for infusion[输血原因]

  红细胞[packed red cells, wshed RBCs]:

  *Hb20% blood volume lost [>20%血容量丢失]

  *cardio-pulmonary bypass with anticipated Hb 10 units[输血10单位以上者]

  *platelet count 15units[输血>15个单位]

  *warfarin or antifibrinolytic therapy with bleeding[华法令或溶栓治疗后出血]

  *DIC[血管内弥漫性凝血]

  *Antithrombin III dficiency[凝血酶III 缺乏]

  (2)输血要求[request for blood components]

  *patient blood group[血型]

  *Has the patient had transfusion or pregnancy in the past 3 months [近3个月,

  病人是否输过血或怀孕过?]

  *Type and crossmatch[血型和血交叉]

  *Units or ml[单位或毫升]

  5、出院小结[discharge summary]

  Patient Name[病人姓名]

  Medical Record No.[病历号]

  Attending Physician[主治医生]

  Date of Admission[入院日期]

  Date of Discharge[出院日期]

  Pirncipal Diagnosis[主要诊断]

  Secondary Diagnosis[次要诊断]

  Complications[并发症]

  Operation[手术名称]

  Reason for Admission[入院理由]

  Physical Findings[阳性体征]

  Lab/X-ray Findings[化验及放射报告]

  Hospital Course[住院诊治经过]

  Condition[出院状况]

  Disposition[出院去向]

  Medications[出院用药]

  Prognosis[预后]

  Special Instruction to the Patient(diet, physical activity)[出院指导(饮食,活动量)]

  Follow-up Care[随随访]

  6、住院/出院病历首页[Admission/discharge record]

  Patient name[病人姓名]

  race[种族]

  address[地址]

  religion[宗教]

  medical service[科别]

  admit (discharge) date[入院(出院)日期]

  Length of stay [住院天数]

  guarantor name [担保人姓名]

  next of kin or person to notify[需通知的亲属姓名]

  relation to patient[与病人关系]

  previous admit date[上次住院日期]

  admitting physician [入院医生]

  attending phgsician[主治医生]

  admitting diagnosis[入院诊断]

  final (principal) diagnosis[最终(主要)诊断]

  secondary diagnosis[次要诊断]

  adverse reactions (complications)[副作用(合并症)]

  incision type[切口类型]

  healing course[愈合等级]

  operative (non-operative) procedures[手术(非手术)操作]

  nosocomial infection[院内感染]

  consutants[会诊]

  Critical-No. of times[抢救次数]

  recovered-No. of times[成功次数]

  Diagnosis qualitative analysis[诊断质量]

  OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率]

  Clinical and pathological Dx concur[临床与病理诊断符合率]

  Pre- and post-operative Dx concur [术前术后诊断符合率]

  Dx determined with in 24 hours (3 days) after admission[入院后24小时(3 天)内确诊]

  Discharge status[出院状况]

  recovered[治愈]

  improved[好转]

  not improved[未愈]

  died [死亡]

  Dispositon[去向]

  home[家]

  against medical ad[自动出院]

  autosy[尸检]

  transferred to[转院到]

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