住院病历英文翻译
英文病历书写要求
原文来自：湘雅医学翻译网MEDICAL RECORD DOCUMENTATIONIncomplete inpatient medical record documentation will be identified by UTMB staff. Y ou will receive written notification of your incomplete record documentation on a weekly basis through U.S. Postal Service mail. UTMB Bylaws and Rules & Regulations of the Medical Staff state that “no record shall remain incomplete, including signatures, greater than thirty (30) calendar days from discharge”.Final Discharge Note (Form 5346)The Final Discharge Note should be completed at the time of discharge. It should be signed (full signature) and dated by the attending physician. Abbreviations should not be used on this form. The following must be recorded on the form:Principal Diagnosis: The condition which, after study, caused admission to the hospital.Complications (if present): Conditions which developed after admission that may have extended the length of stay and required use of additional resources.Comorbidities (if existing): Conditions present prior to admission that could extend the length of stay or require additional resources.Principal Procedure: The definite/therapeutic procedure most closely related to the principal diagnosis.The discharge plan must be documented, and the availability of appropriate services to meet the patient’s needs after hospitalization must be addressed.History and Physical Examination (Form 2005)A complete history and physical examination shall, in all cases, be written and placed in the record within twenty-four (24) hours after admission of the patient. If a complete history and physical has been obtained within thirty (30) days prior to admission in a physician’s office, a durable legible copy of this report may be used in the patient’s hospital medical record, provided there have been no subsequent changes or if there were changes, the changes have been recorded at the time of admission. A durable, legible original or reproduction of the office or clinical prenatal record is acceptable.The history and physical examination includes at a minimum the patient’s chief complaint, present illness/injury, review of systems, past history, family history and physical examination. The patient’s biophysical, psychosocial, cultural, spiritual, developmental, educational, functional,nutritional, and pain/comfort needs will be addressed as appropriate. The physician H&P will be filed in the H&P section of the medical record.The attending physician must sign and date the History and Physical Examination.Inpatient Progress Note (Form 5300)Inpatient progress notes shall be written to provide a chronological record of the patient’s progress. Notes should be timely, legible, relevant, and sufficiently detailed to permit and justify continuity of care. Progress notes on procedures/operations should also include doctor number after the signature. All notes must be timed, dated and signed. A progress note should be written by a physician everyday and more often on critical patients.Operative ReportAn operative note must be written and dictated immediately after surgery and should include the items listed below. The report is signed by the appropriate physician(s).1.preoperative diagnosis;2.postoperative diagnosis; of procedure;4.description of findings;5.technical procedure used;6.specimens removed; of primary surgeon and any assistants; and8.condition of patient after surgery.Discharge SummaryA discharge summary is required on patients discharged from the hospital and should be completed at the time of discharge.The Discharge Summary must contain:, UH#, date of admission, date of discharge, and attending physician;2.chief complaint or reason(s) for admission;3.significant history and physical findings;4.pertinent laboratory and x-ray findings;5.treatment rendered;6.princ ipal and additional or associated diagnoses (indicate principal);7.surgical procedures; and8.disposition –include specific instructions given to the patient and/or family, aspertinent (including instructions relating to physical activity, medication, diet, andfollow-up care);9.prognosis.The physician is required to sign and date the discharge summary.Dictated/typed discharge summaries are not required in the following situations:1.normal obstetric deliveries, including uncomplicated cesarean sections;2.normal newborns.see:/Article/ShowArticle.asp?ArticleID=851。
病历翻译样例-入院记录
病历翻译样例-入院记录泛瑞翻译病历翻译作为出国看病的基本依据，应当引起医学翻译工作者的严肃对待。
译者不但要完全明白病历意思，更要以合理的逻辑思维及语言表达来表述病历内容。
病历翻译主要涉及CT、MRI检查、生化检查、出院小结、入院记录等。
所有这些内容都要求准确翻译，不能出现乱译的现象。
但有时候，会因为中文与英文的表述习惯，出现一定的字面偏颇。
根据知情同意的原则，翻译公司有必要进行书面描述，以避免不必要的理解错误。
下面列举一个病历翻译样例：History of present illness: On October 23, 2012, physical examinations revealed that the patient’s serum creatinine was 278umol / L, hematuria was + +, proteinuria was + +. Subsequently, she was treated at Peking University First Hospital on November 14, 2012, and her blood pressure was 140/90mmHg. Blood IgA was 3.93g / L, and 24-hour urinary protein was 2.97 g (urine volume 1500 mL). Microscopy for urine red blood cell phase difference revealed a high red blood cell distortion rate. Bilateral renal B ultrasound showed a slightly smaller right kidney, and the renal parenchyma was slightly thin. She was admitted to hospital for treatment, and carried out a renal biopsy. The pathologic report revealed crescentic IgA nephropathy (moderate to advanced).During the hospitalization, the serum creatinine, blood uric acid, and hemoglobin were 390.6 umol/L, 499 umol/L, and 93 g/L, respectively. She was diagnosed with chronic glomerulonephritis, crescentic IgA nephropathy (moderate to advanced), renal anemia, renal hypertension, and hyperuricemia. Thus, treatments including hypertension-relieving and anemia-correction were given. The patient's condition was stable after discharge. Oral administration of allopurinol was recommended (2 tablets each time, t.i.d.). After 2 weeks, the recheck of blood biochemical indexes was performed, which showed the levels of alanine aminotransferase, aspartate aminotransferase, albumin, and serum creatinine were 52 IU/L, 71 IU/L, 33.2g/L, and 55 umol L, respectively. Meanwhile, systemic red rash was reported. Subsequently, she was admitted to our department. As she was speculated to suffer from acute exacerbation of chronic renalinsufficiency, acute drug-induced liver injury, drug-induced dermatitis, symptomatic treatments including administration of hormones, liver-protection, renal function protection were performed accordingly. She was discharged after her condition was improved. At this time, she was admitted to our department to adjust the amount of hormone. Presently, the patient's condition is stable with satisfactory mental condition and appetite. The patient reported no cough or expectoration. Additionally, no painful swelling of joint or fever was reported. No abnormality was observed in the defecation and urination. No significant changes were noted in her body weight.。
soap英文病历
soap英文病历Title: SOAP English Medical RecordsIntroduction:SOAP (Subjective, Objective, Assessment, Plan) is a widely used method for documenting patient information in medical records. This article aims to provide an accurate and comprehensive overview of SOAP English medical records. The article will be structured with an introduction, main body, and conclusion. The main body will consist of five major points, each divided into 3-5 subpoints, explaining the intricacies of SOAP English medical records.Main Body:1. Subjective:1.1 Patient Background:- Provide patient demographic information such as name, age, gender, and contact details.- Include relevant medical history, including previous illnesses, surgeries, and allergies.- Document the patient's chief complaint, presenting symptoms, and duration of symptoms.- Record any relevant information provided by the patient or their family members.1.2 Present Illness:- Describe the current medical condition in detail, including the onset, progression, and severity of symptoms.- Document any factors that may have contributed to the illness.- Include a timeline of events leading up to the current condition.- Record any treatments or medications the patient has already tried.1.3 Review of Systems:- Systematically document the patient's symptoms and complaints related to each body system.- Include information on constitutional symptoms, such as fever, weight loss, or fatigue.- Record any positive or negative findings in each system, such as respiratory, cardiovascular, gastrointestinal, etc.- Mention any relevant family history that may impact the patient's condition.2. Objective:2.1 Physical Examination:- Document the findings of a thorough physical examination, including vital signs, general appearance, and specific organ system assessments.- Describe any abnormalities or notable observations.- Include results of laboratory tests, imaging studies, or other diagnostic procedures.- Record the patient's height, weight, and body mass index (BMI).2.2 Assessment:- Summarize the healthcare provider's assessment of the patient's condition.- Include a differential diagnosis, listing possible conditions based on the subjective and objective findings.- Discuss any further diagnostic tests required to confirm or rule out specific conditions.- Mention any consultations or referrals to other specialists.2.3 Diagnostic Impressions:- Provide a concise summary of the confirmed diagnosis or a list of potential diagnoses.- Include the rationale behind the diagnosis, considering the patient's symptoms, physical examination, and test results.- Discuss any complications or comorbidities related to the diagnosis.- Mention any chronic conditions that may impact the patient's current illness.3. Plan:3.1 Treatment Plan:- Outline the proposed treatment options, including medications, therapies, or procedures.- Specify the dosage, frequency, and duration of medications.- Discuss potential side effects or contraindications of the chosen treatment.- Mention any lifestyle modifications or patient education required.3.2 Follow-up:- Schedule any necessary follow-up appointments or tests.- Specify the expected timeline for improvement or resolution of symptoms.- Discuss any potential red flags or warning signs that require immediate medical attention.- Mention any referrals to other healthcare providers or specialists.3.3 Patient Education:- Provide information to the patient regarding their condition, treatment options, and expected outcomes.- Discuss any lifestyle modifications or self-care measures the patient should undertake.- Address any concerns or questions the patient may have.- Offer resources or references for additional information.Conclusion:In conclusion, SOAP English medical records provide a structured and comprehensive approach to documenting patient information. The subjective section captures the patient's background, present illness, and review of systems. The objective section includes physical examination findings and diagnostic impressions. The plan section outlines the treatment plan, follow-up, and patient education. By following this organized format, healthcare providers can ensure accurate and consistent documentation of patient care.。
病历书写英文
英文病历书写常用句式与表达
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英文病历书写注意事项
04
Spelling mistakes
Typing errors or misspellings of words and names.
Grammar mistakes
Incorrect usage of verbs, nouns, adjectives, and pronouns, and incorrect sentence structure.
实例三：糖尿病病历
Symptoms：Itching, skin redness and scalingMedical history：None significantFamily history：None contributoryReview of systems：NegativePhysical examination：Multiple small red patches and scaling on the skin of the upper back and upper armsDiagnostic studies：Skin scrapings showed positive fungal elementsDiagnosis：DermatitisPlan：Patient was advised to apply topical corticosteroid cream twice daily and follow up in 1 week
实例二：高血压病历
Symptoms：Polyuria, polydipsia, unexplained weight lossMedical history：Known diabetes mellitus for 2 years, taking metformin hydrochlorideFamily history：None contributoryReview of systems：NegativePhysical examination：Blood pressure 130/85, pulse 90 beats/minute, respiration rate 18 breaths/minute, weight 150 poundsDiagnostic studies：Random blood glucose level of 250 mg/dL, HbA1c of 7.5%Diagnosis：Diabetes mellitusPlan：Patient was advised to continue current medications, receive education on diabetes self-management, lose weight, reduce glucose intake, and follow up in 3 months
常用医疗、医药英文翻译
Bian mi
Constipation
肝脏
Gan zang
Liver
腹泻
Fu Xie
Diarrhea
胰脏
Yi zang
Pancreas
肠鸣
Chang ming
Rumbling sound
胆囊
Dan nang
Gall bladder
放屁
Fang pi
Pass gas
盲肠
Mang chang
Appendix
剧痛
Jv tong
Severe pain
高烧
Gaoshao
High fever
打喷嚏
Da pen ti
Sneeze
发冷
Fa len
Chills
打嗝
Da ge
Hiccup
发汗
Fa han
Sweats
痒
Yang
Itch
盗汗
Dao han
Night sweats
腰痛
Yaotong
Lower back pain
药丸
Yaowan
Tablet. Pill
药方
Yaofang
Prescription
症状及名称zheng zhuang ji ming chen (Symptoms)
一般症状yi ban zheng zhuang (General)
中文名称
汉语拼音
英文名称
中文名称
汉语拼音
英文名称
发烧
Fa shao
Fever
倦怠
Juan dai
Tiredness
头痛
Tou tong
Headache
门诊病历书写规范模板
门诊病历书写规范模板门诊病历是诊断和治疗疾病的重要文件，对于医生来说，书写规范的门诊病历能够排除歧义，保证病历信息准确完整，提高医疗质量。
下面是一份门诊病历书写规范模板（英文翻译）。
1. Personal InformationName:Gender:Age:Occupation:Address:Contact Number:2. Chief ComplaintPlease describe your main reason for seeking medical attention.患者主诉：3. Present IllnessPlease provide a detailed description of your current illness, including when it started, the progression of symptoms, and any factors that may have worsened or improved the condition.患者现病史：4. Medical HistoryPlease provide information about any previous medical conditions, surgeries, or hospitalizations.患者既往史：5. AllergiesPlease list any known allergies, including medication allergies.患者过敏史：6. MedicationsPlease list any medications that you are currently taking, including dosage and frequency.患者用药史：7. Family HistoryPlease provide information about any significant medical conditions that run in your family.家族史：8. Social HistoryPlease provide information about your lifestyle and any habits that may affect your health, such as smoking, alcohol use, or drug use. 社会史：9. Review of SystemsPlease provide information about any additional symptoms or concerns you may have, including details about your cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and nervous systems, as well as your skin, eyes, ears, and throat.患者系统回顾：10. Physical ExaminationPlease provide a summary of your physical examination findings, including vital signs, general appearance, and any specific abnormalities identified during the examination.体格检查：11. DiagnosisPlease provide a provisional or confirmed diagnosis based on your medical history, physical examination, and any diagnostic tests performed.临床诊断：12. InvestigationsPlease list any diagnostic tests that have been performed or ordered, including laboratory tests, imaging studies, or other investigations. 检查规格：13. TreatmentPlease provide details about any treatments that have been prescribed or administered, including medication, dosage, frequency, and any other relevant information.治疗方案：14. Follow-up PlanPlease provide information about any follow-up appointments, tests, or referrals that have been recommended or scheduled.随访计划：15. Advice and InstructionsPlease provide any advice or instructions that have been given to the patient, including information about medication side effects or precautions.医嘱：16. PrognosisPlease provide an assessment of the patient's prognosis, including any potential complications or long-term consequences of the current illness.预后评估：17. SignaturePlease sign and date the medical record to indicate that you have reviewed and confirmed its contents.医生签名日期：以上是一份门诊病历书写规范模板，对每个部分都进行了详细说明，希望能为医生书写规范的门诊病历提供参考。
医院科室英语翻译大全
医院科室英语翻译大全ENT(ear-nose-throat)department: 耳鼻喉科urology department: 泌尿科dermatology department; skin department: 皮肤科orthopedic surgery department: 矫形外科traumatology department: 创伤外科plastic surgery: 整形外科anesthesiology department: 麻醉科pathology department: 病理科cardiology department: 心脏病科psychiatry department: 精神病科orthopedics department: 骨科department of cardiac surgery: 心脏外科department of cerebral surgery: 胸外科neurology department: 神经科neurosurgery department: 神经外科thoracic surgery department: 脑外科department of traditional Chinese medicine: 中医科registration office: 挂号处out-patient department: 门诊部in-patient department: 住院部nursing department: 护理部consulting room: 诊室waiting room: 候诊室emergency room: 急诊室admitting office: 住院处operation room: 手术室X-ray department: 放射科blood bank: 血库dispensary; pharmacy: 药房ward: 病房laboratory: 化验室牤Department of Nephrology 肾内科Department of Chemotherapy 化疗科Department of Radiotherapy 放疗科Department of Endocrinology 内分泌科Respiratory medicine 呼吸科Rheumatology 风湿科Hematology 血液科Geriatrics 老年科Neurology 神经科Oncology 肿瘤科Thoracic surgery 胸外科Urology 泌尿外科Neurosurgery 神经外科Vascular surgery 周围血管外科Gastroenterology 肠胃外科Hepatobiliary surgery 肝胆外科General surgery 普外科Orthopedics 骨科Cardiovascular surgery 心外科Burns surgery 烧伤科Hand surgery 手外科Plastic surgery 整形外科Pediatric surgery 儿外科Obstetrics and gynecology 妇产科Stomatology 口腔科Ophthalmology 眼科Infectious disease 感染科Dermatology 皮肤科Otorhinolaryngology (ENT) 耳鼻喉科Nuclear medicine 核医学科Psychiatry 精神科Medical rehabilitation 康复科Anesthesiology 麻醉科Radiology 放射科Ultrasonography 超声科Pain management 疼痛科Pharmacology 药理科Internal Medicine 内科医院科室牌中英文对照科室牌英文翻译行政办公室administratve office院长办公室President's Office导向咨询Enquiry挂号处Registration专科门诊一览表Schedule for Special Out-patient门诊病案室Outpaient Medical Records西药房Pharmacy中药房Pharmacy of Traditional Medicine中西药取药处Pharmacy Dispenser登记划价处Account of Medicine收费处Cashier门诊检验Clinical Laboratory标本接受处Specimen-Reception门诊输液中心Out-Patient Infusion Center注射室Injection Room取报告单处Iaboratory Report换药室/治疗室Bandage Change/Treatment Room污洗室Cleaning Room洗手间Toilet茶水间Drinking Room男更衣Men's Dressing Room女更衣Women's Dressing Room门诊接待室Reception Room候诊厅Waiting Lobby中西医结合门诊Clinic of Integrated Traditional & Western Medicine 内科Dept.of Internal Medicine神经内科Neurology心血管内科Cardiovasology呼吸内科Respiratory Medicine呼吸隔离诊查室Examination for Respiratory消化内科Gastroenterology肾内科Nephrological Dept.泌尿内科Urologic Dept.关节内科Arthrology肿瘤内科Medical Oncology口腔内科Oral Medicine外科Surgery外科诊室Surgical Clinic头颈外科Head & Neck Surgery心胸外科Cardiothoracic Surgery胸外科Thoracic Surgery创伤外科Traumatic Surgery泌尿外科Urology Surgery显微外科Micro Surgery口腔颌面外科Dental Restoration Technician Room骨科Orthopaedics骨伤科Orthopedic Surgery手法复位室Manipulation of Bone-Setting Room妇产科Gynecology & Obstetrics妇科检查室Examination for Gynecology产科门诊Obstetrics Clinic计划生育门诊Family Planning Clinic生殖中心Reproductive Center儿科Pediatrics儿童娱乐室Amusement Room for Children儿童保健部Child Hygiene儿童生长资料室Data Room of Children Development新生儿疾病专科Newborns Disease Dept.中医科Traditional Chinese Medicine中医门诊Traditional Chinese Medicine Clinic中医正骨O.P.D of Bone Setting针灸科Acupuncture & Moxibustion针推理疗科Acupuncture Massage & Physical Therapy 皮肤科Dermatology皮肤科治疗室 Treatment Room for Dermatology皮肤性病科 Dermatology & STD康复科Rehabilitation Dept.康复诊疗室Consultation Room脑瘫痪康复门诊Rehabilitation Clinic for Encephalic Paralysis 功能康复室Function Rehabilitation Room健康资料放置处Health Data肠道门诊Gastroenterology Clinic肠道病诊室Consulting Room for Intestinal Diseases肠道隔离诊查室Isolation Room for Intestinal Disease肠道治疗室Therapy Room for Enterology肠道传染病门诊Intesti Infectious Disease Clinic隔离室Isolation Room肝炎专科Division of Hepatitis结核门诊Tuberculosis Clinic老年病科Gerontology Dept.内分泌科Endocrinology血液专科Division of Hematology疼痛门诊Painful Disease Clinic疼痛门诊观察室Observation Room for Painful Disease Clinic 疼痛门诊治疗室Treatment Room for Painful Disease Clinic 其他心理咨询Psychology Consulting佝偻病专科Rachitis Dept.神经、脊柱Neurolohy Rachitis神经科Neurology贵宾（特需）门诊VIP Clinic体检中心Physical Examination Center风湿专科Rheumatism挂号须知Notes for Registration请便后冲水Please Flush After Use请勿吸烟Please No Smoking未经批准不得进入No Admittance严禁吸烟No smoking医患沟通园地Patient-Doctor Communication Grounds在此候诊Waiting Aera暂停服务Service Suspended急诊部急救分中心办公室Office of Branch Emergency Center 急救中心Emergency Center抢救室Emergency Treatment Room急诊诊疗室Emergency Room急诊化验室Emergency Laboratory急诊收费Emergency Cashier急诊药房Emergency Pharmacy输液室Infusion Room抢救监护室First-aid Care Room急诊仪器室Emergency Instrument Room医师办公室Physician's Office观察区Observation Ward医技科室药剂科Pharmacy Dept.药剂科办公室Pharmacy Office药剂科会议室Meeting Room of Pharmacy制剂研究室Preparation Research Room西药调剂室Prescription Room of Medicine中药调剂室Prescription Room of TCM普通制剂室General Preparation Room中药制剂室Preparation Room for TCM西药库 Medicine Store中药库 TCM Store一次性物品库DisposabLe Storage Room病理科Pathology Dept.标本前处理室Sample Preparation Room标本室Specimen Station标本收集处Specimen Reception标化室Specimen Laboratory病理技术室Pathological Technology Room病理切片室Section Room影像诊断中心Radiodiagnosis Center放射科Radiology Dept.放射治疗中心Radiation Oncology Center核医学科Nuclear Medicine DepartmentX光室X-Ray RoomCT室CT Scan RoomCT准备室Preparation Room for CT核磁共振MRI读片室Radiodiagnosis Center暗房Darkroom照相机室Camera Room摄影室Photography Room安全门ExitPT室PT RoomOT室OT Room图像工作站PACS Room放疗科Radiation Oncology Dept.放免室Radiological Immunology Room放射化学室Radiochemistry & Radiopharmaceuticals放射检疫生化室Radioimmunochemistry & Biochemistry直线加速器1室Linear Accelerator Room 1后装治疗机室Therapeutic Room模拟室位机室Simulative Localizer Room模拟机室Simulator Room模型室Model Room心电图室ECG Lab动态血压室IBP心功能室Cardiac Function Room心脏多普勒超声检查室Colour Echo or UCG平板运动心电图室Stress Test超声科Doppler Ultrasonic Department肺功能室Pulmonary Function Room肺功能检查室Pulmonary Function Test Room肺通气室Pulmonary Ventilation内镜中心Endoscopy Center产房Delivery Room产房办公室Office for Delivery Room产房值班室On-Duty Room for Delivery待产室Predelivery Room隔离室Isolation Room盥洗室Rest Room配餐间Diet Room配液室/药物配置室Pharmacy Preparation清洁室Cleaning Room洗涤室Washing Room储物室Store工作人员洗手间Rest Room for Staff Only领衣帽处Clothing Center房间号Room Number住院病人一览表In-patient List请放病历Please Put Your Medical Record便盆放置处Bedpan Here病人一览表Patient General Table医疗查房时间请勿打扰Please Don't Disturb During Ward Round 保障部门总务办公室Office of Dispatch Service Center水泵机房Water Pump Control Room水处理室Water Treatment Room消防控制室Fire Control Room空调机房Air-Conditioner Controlling Room气瓶间Gas Bottle Room冷冻机房Refrigerator Room配电房Power Room配电值班室On-Duty Room for Electricity太平间Mortuary洗衣房Laundry总机室Telephone Exchange Room停车场Park传达室Janitor Room修理间Repair Room机修室Machinery Maintenance排污机房Sewage Disposalr设备层Equipment Floor地下室Basement电梯Elevator楼梯通道Stair Passageway心理咨询Psychology Consulting佝偻病专科Rachitis Dept.神经、脊柱Neurology Rachitis神经科Neurology贵宾（特需）门诊VIP Clinic体检中心Physical Examination Center风湿专科Rheumatism挂号须知Notes for Registration请便后冲水Please Flush After Use请勿吸烟Please No Smoking未经批准不得进入No Admittance严禁吸烟No Smoking医患沟通园地Patient-Doctor Communication Grounds 在此候诊Waiting Aera暂停服务Service Suspended急诊部急救分中心办公室Office of Branch Emergency Center 急救中心Emergency Center抢救室Emergency Treatment Room急诊诊疗室Emergency Room急诊化验室Emergency Laboratory急诊收费Emergency Cashier急诊药房Emergency Pharmacy输液室Infusion 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入院记录的英语作文
入院记录的英语作文English Answer：Case Number: 241010。
Patient: John Smith.Reason for Admission: Syncope.History of Present Illness:The patient is a 60-year-old male who presents with a chief complaint of syncope. He reports that he has been experiencing episodes of dizziness and lightheadedness for the past 2 weeks. These episodes have been occurring more frequently and have now progressed to syncope. The patient states that he has not had any chest pain, shortness of breath, or palpitations associated with his episodes.The patient's past medical history is significant forhypertension and hyperlipidemia. He is currently taking lisinopril and simvastatin. He denies any history of smoking, alcohol use, or illicit drug use.Physical Examination:Vital signs: BP 140/80 mmHg, HR 70 bpm, RR 16 breaths/min, T 37.0°C (98.6°F)。
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最全的医学英语之NO.12014-03-05保研助手最全的医学英语之NO.11、抗生素医嘱[Antibiotic order]Prophylaxis 预防性用药Duration of oder 用药时间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Cultures ordered 做培养Documented infection 明确感染Site and organism 部位和致病菌Explanation required 解释理由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 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 姓名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 Systems 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, washed RBCs]:*Hb<8.5 [血色素<8.5]*>20% blood volume lost [>20%血容量丢失]*cardio-pulmonary bypass with anticipated Hb <8[心肺分流术伴预计血色素<8]*chemotherapy or surgery with Hb <10[血色素<10的化疗或手术者]▲全血[whole blood]:massive on-going blood loss[大量出血]▲血小板[platelets]:*massive blood transfusion >10 units[输血10单位以上者]*platelet count <50×103/μl with active bleeding or surgery[血小板<5万伴活动性出血或手术者]*Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流术伴血小板<10万，活动性出血者]*Platelet count <20×103/μl[血板<2万]▲新鲜冰冻血浆[fresh frozen plasma]:*documented abnormal PT or PTT with bleeding or Surgery[PT、PTT异常的出血或手术病人]*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手术者]*blood transfusion >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]阅读原文举报。