medical record
Guide to Medical Records
GUIDE TO MEDICAL RECORDSGeneral Data: name, age, sex, occupation, marital status (S., M., W., D.)1. Chief Complaint: weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration (inspiration+expiration), shortness of breath, bleeding or discharge, etc.2. Present Illness: onset (date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms前驱症状, general symptoms, course or progress (location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.3. Past History:a.Former places of residence, previous state of health (robust, delicate), experiencewith similar disease, immunity to/against/towards infectious diseases.b.Previous illness: measles, mumps, chicken-pox, pertussis, influenza, scarlet fever,（猩红热）diphtheria, typhoid fever, bronchitis, pneumonia, encephalitis, meningitis, tetanus, poliomyelitis, dysentery痢疾, cholera霍乱, pleurisy, smallpox, tonsillitis, rheumatism, asthma, malaria, tuberculosis, jaundice, allergy, etc.c.Venereal disease: specific symptoms and signs, treatment, etc.d.Accidents (date, any disability, sequelae); operation and hospitalization (date,procedure, name of hospital, physician, complications, bleeding tendency).4. Family History: family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilepsy, allergy, etc. any contact with diseased individuals, relationship of patient’s child hood and adult life; age, health condition, and cause of death of parents, grandparents, self, spouse, siblings or relatives.5. Personal History:a.Social history: fears, mental status, education, financial condition, number ofdependents, family harmony or friction, hygienic condition at home.b.Marital history: duration of marriage, 1st or 2nd marriage, age and health of spouseand children, if died, cause and age at time of death, number of children, number of pregnancies, miscarriages, stillbirths.c.Occupational history: duration of employment, past work, exact nature of work,exposure to occupational hazards, whether work is satisfactory or not.d.Habits: alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity ofmeals, rapidity of eating, bowel movements, sleep, exercise, interests, etc.主诉咽痛、高烧两天。
英语病历报告作文格式
英语病历报告作文格式Patient Medical Record Report.Patient Information:Full Name: John Doe.Gender: Male.Age: 45。
Address: 123 Main Street, City, State, Country.Contact Number: +1234567890。
Presenting Complaints:Mr. Doe presented with complaints of persistent chest pain, shortness of breath, and fatigue for the past two months. He reported a history of smoking for the past 20years and occasional alcohol consumption. There was no history of similar episodes in the past.Physical Examination:General: Mr. Doe appeared to be in moderate distress. His skin was pale, and there were no signs of jaundice or cyanosis.Cardiovascular: Heart rate was elevated at 100 beats per minute with irregular rhythm. Auscultation revealed a murmur in the mitral area.Respiratory: Breath sounds were diminished in the left lung base with evidence of crackles.Abdominal: Soft, non-tender abdomen with no organomegaly.Neurological: No focal neurological deficits were noted.Diagnostic Tests:Electrocardiogram (ECG): Showed irregular heartbeat with evidence of atrial fibrillation.Chest X-ray: Revealed enlarged heart with pulmonary congestion.Echocardiogram: Confirmed the presence of mitral valve regurgitation.Medical History:Mr. Doe had a history of hypertension for the past five years, which was well-controlled with medication. He had no known allergies to any medications. His family history was unremarkable for any cardiovascular diseases.Differential Diagnosis:Coronary Artery Disease (CAD)。
丙级病历检讨及整改报告范文
丙级病历检讨及整改报告范文English.Introduction.The purpose of this medical record review andcorrective action report is to identify deficiencies in the medical record documentation and to develop a plan to correct these deficiencies. This report is based on a review of 20 medical records from the Department of Medicine at XYZ Hospital.Deficiencies Identified.The following deficiencies were identified:Incomplete or missing documentation of history of present illness.Inadequate physical examination findings.Lack of documentation of informed consent for procedures.Incomplete or missing documentation of medication administration.Lack of documentation of patient education.Root Causes.The root causes of these deficiencies were identified as:Lack of training on proper medical record documentation.Time constraints.Lack of awareness of the importance of medical record documentation.Corrective Actions.The following corrective actions are recommended:Provide training on proper medical record documentation to all medical staff.Increase the time allotted for medical record documentation.Increase awareness of the importance of medical record documentation.Implement a system to track and monitor medical record documentation.Monitoring.The progress of the corrective actions will be monitored by the Department of Medicine. Regular reports will be provided to the hospital administration.Conclusion.The implementation of these corrective actions will improve the quality of medical record documentation at XYZ Hospital. This will lead to improved patient care and reduced risk of medical errors.Chinese.中文回答：导言。
消化不良门诊病历书写范文
消化不良门诊病历书写范文英文回答：Digestive problems are a common issue that many people experience. It can be caused by various factors such as poor diet, stress, or underlying medical conditions. When a patient comes to the digestive clinic with complaints of indigestion, bloating, or stomach pain, it is important for the medical staff to accurately document their symptoms and medical history in the medical record.In the case of a patient presenting with digestive problems, the medical record should include a detailed description of the symptoms experienced by the patient. For example, the patient may complain of a burning sensation in the stomach, accompanied by frequent burping and a feeling of fullness after meals. These specific details can help the healthcare provider to better understand the nature of the problem and make an accurate diagnosis.The medical record should also include information about the patient's medical history and any relevant past treatments. For instance, if the patient has a history of gastritis or acid reflux, this information should be documented. Additionally, any medications that the patient is currently taking, such as antacids or proton pump inhibitors, should be noted in the medical record.Furthermore, it is important to document any lifestyle factors that may be contributing to the patient's digestive problems. This could include dietary habits, such as consuming spicy or fatty foods, or lifestyle choices such as smoking or excessive alcohol consumption. These factors can play a significant role in the development of digestive issues and should be taken into consideration during the evaluation and treatment of the patient.In addition to documenting the patient's symptoms, medical history, and lifestyle factors, the medical record should also include the results of any diagnostic teststhat have been conducted. This could include laboratory tests such as blood work or stool analysis, as well asimaging studies such as an abdominal ultrasound or endoscopy. These test results can provide valuable information to aid in the diagnosis and treatment of the patient.Overall, the documentation of a patient's digestive problems in the medical record is crucial for providing quality healthcare. It allows for accurate communication between healthcare providers, ensures continuity of care, and helps to guide treatment decisions. By thoroughly documenting the patient's symptoms, medical history, lifestyle factors, and diagnostic test results, healthcare providers can provide effective and personalized care to patients with digestive issues.中文回答：消化不良是许多人常见的问题。
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.。
医疗文书清单目录流程
医疗文书清单目录流程Creating a medical record directory process can be challenging yet crucial in maintaining organized and efficient patient information. The first step in setting up a medical record directory is to establish a standardized naming convention for the different types of documents. 这是建立一个医疗文档清单目录流程的关键步骤。
需要建立一个标准的命名规范，以便对不同类型的文件进行统一命名。
Once the naming convention is established, the next step is to categorize the medical records into different sections such as patient demographics, history and physical examination, laboratory test results, progress notes, and radiology reports. 确立了命名规范之后，下一步是将医疗文档分类到不同的部分，如患者人口统计学信息、病史和体格检查、实验室检验结果、病程记录和放射学报告。
It is important to have a clear and easily accessible filing system in place to ensure that medical records can be located quickly and accurately. The use of electronic medical record (EMR) systems can significantly improve the efficiency of accessing and organizing patient information. 对于建立一个清晰易于访问的文件存档系统非常重要，以确保能够快速准确地定位医疗文档。
医院标识中英文对照
医院标识中英文对照中药局Chinese Medicine Pharmacy公用电话Public Telephone/Pay Phone/Telephone/Public Phone日常生活训区Daily Activity Training日间门诊Clinic Area日间院Adult Day Care Center日间照护Day Care Center出院室Discharge Office加护病房Intensive Care Unit(ICU）打卡刷卡区Clock In / Out民众意箱Suggestions各科门诊Out—Patient Departments(OPD）早产儿室Premature Babies自动提款机ATM住院室Admissions佛堂Buddhist Prayer Room吸烟区Smoking Area志工服务台Volunteer Services志工室Volunteers衣室Dressing Room巡箱Patrol Box夜间门诊Evening Clinic居家护Home Health Care居家护室Home Health Care服务台（询问处）Information注射室Injections治室Treatment Room社福卫教室Social Work and Health Education门诊大厅Outpatient Hall门诊注射室Outpatient Injection门诊部Out-patient门诊满意调查回收意箱Suggestion Box门诊检验OPD Laboratory待产室Labor Room急诊暂观察室ER Observation Room恢室Recovery Room候诊区Waiting Area员工意箱Suggestions晒衣场Clothes Drying气喘卫教室Asthma Health Education Room消毒室Sterilization消毒锅区Equipment Sterilization病房Ward病毒室Viral Laboratory健儿门诊Well Baby Clinic医院常用中英文对照汇编公共空间健保卡换卡服务中心National Health Insurance Card Renewal 健检中心Physical Examination Center健检室Physical Examination产后妇中心Postpartum Care Center产后护之家Postpartum Care发烧筛检站Fever Clinic诊室Consulting Room新生儿病房Neonatal Ward隔检疫舍Quarantine House团体治室Group Therapy语言治室Speech Therapy药处Medicine Receiving卫教公布Health Education Bulletin Board卫教室Health Education Office婴儿室Baby Room检查室Examination Room总层引Floor Plan转诊中心Referral Center药物谘询Drug Information药库Drug Storage护之家Nursing Home台Terrace接待，服务及休闲区水间Kitchen / Drinking water / Hot Water饮水机Drinking Fountain配膳间Meal Checking发厅Barbershop美发(容)院Beauty Salon商店街Shopping Arcade员工餐厅Staff Restaurant / Cafeteria餐厅Restaurant西餐厅Western Restaurant贵宾室Guest Room / Reception会客室Reception Room休息室Lounge家属休息室Lounge图书室Library阅览室Reading Room放映室Projection Room影印室Copy Room育婴室Nursery Room / Mother and Baby Room哺乳室Nursery Room值班室Duty Room驻警室Security警卫室Security Room接待,服务及休闲区停管中心Parking Service Center调室Dispatch Room司机室/司机调室Drivers‘ Lounge值日室Duty Room值班休息室Duty Office医师休息室Physicians‘ Lounge宿舍Dormitory儿童游戏场Recreation Area医器材贩卖部Medical Supply Dispensary爱心椅Courtesy Wheelchairs椅借用区Movable Beds政单位人资源部Human Resources Department人事室Personnel Office人事组Personnel Section人事处Department of Personnel公安室Industrial Safety Office工务科Maintenance公关室Public Relations Room (Office) 文卷室Documentation and Archives Office主计室Comptroller Office出纳室Cashier出纳课Cashier Section民诊处Civilian Administration Division企划室Strategy Planning Office企划组Planning Section企划组Planning and Management Section企划管部Planning and Management Division 安全卫生室Labor Safety and Hygiene成本执组Cost Management Section收发室Mail Room政副院长室Administrative Deputy Superintendent政管中心Administration住/出/转院Admission/Discharge/Transfer住院病组Inpatient Records Unit兵役复检室Military Service Examination批价柜台Cashier系统组System Engineering Section防台中心Typhoon Emergency Center社会服务室Social Worker Room社区副院长室Community Deputy Superintendent 社会服务科Social Service Section门诊病组Outpatient Records Unit 保险作业组Insurance Declaration Section急诊批价ER Cashier科主任办公室Dept。
病历卡英文模板
病历卡英语作文篇一英文作文：Last week, I woke up feeling really terrible. My head was pounding, and I had a high fever. So, I decided to go to the hospital. When I arrived at the hospital, I realized that I had forgotten to bring my medical record card. Oh no! This made the whole process so much more complicated. The doctor had to ask me a bunch of questions about my medical history, which I tried my best to remember and answer. But it was so hard to recall everything accurately. If I had brought my medical record card, the doctor could have easily looked at my past diagnoses, treatments, and allergies. It would have saved so much time and effort. After a long wait and a series of examinations, the doctor finally diagnosed my problem. But without the medical record card, it took much longer than it should have. This experience really made me realize how important it is to always bring your medical record card when going to see a doctor. It can make the whole process smoother and ensure that the doctor can provide the best possible treatment.中文翻译:上周呀，我一觉醒来感觉特别糟糕。
平行病历范文1000字
平行病历范文1000字 英文回答： Parallel Medical Record. A parallel medical record is a patient's medical history that is maintained separately from their electronic health record (EHR). Parallel medical records are often used by patients who have complex or chronic conditions, or who are concerned about the privacy of their medical information.
There are a number of benefits to using a parallel medical record. First, it can help patients to better manage their care by providing them with a centralized location for all of their medical information. Second, parallel medical records can help patients to communicate with their healthcare providers more effectively, as they can provide a more comprehensive view of the patient's medical history. Finally, parallel medical records can help to protect patients' privacy by keeping their medical information out of the EHR system.
病历书写错误检讨书范文
病历书写错误检讨书范文英文回答：I would like to apologize for the errors in my medical record writing. I understand the importance of accurate and clear documentation in patient care, and I take full responsibility for the mistakes made.One of the errors I made was misspelling the patient's name. Instead of writing "John Smith," I mistakenly wrote "John Smyth." This mistake occurred due to a typing error, and I failed to double-check the information before finalizing the record. This error could potentially cause confusion and may lead to incorrect treatment or medication administration. I deeply regret this oversight and assure you that I will be more vigilant in the future to prevent such mistakes.Another mistake I made was omitting important details in the patient's medical history. In the record, I failedto mention that the patient has a history of allergies, specifically to penicillin. This omission could have serious consequences if the patient were to be prescribed penicillin-based medication in the future. I understand the importance of documenting all relevant information to ensure safe and effective patient care. I apologize forthis oversight and will make sure to include all necessary details in future medical records.Furthermore, I realize that my handwriting in the medical record was illegible in some areas. This could lead to misinterpretation of the information by other healthcare professionals involved in the patient's care. I understand that clear and legible handwriting is crucial in medical documentation to ensure accurate communication and prevent misunderstandings. I apologize for any inconvenience caused and will make a conscious effort to improve my handwriting to avoid such issues in the future.中文回答：我对我在病历书写中的错误表示道歉。
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The Second Affiliated Hospital of Soochow University Problem-Oriented Medical Records for Admission General data
Name：
Age： Sex: Marital status: Birth of place: Race: Address: Occupation: Complainer: Reliability: Time of admission: Time of record:
History Chief complaint:
History of Present illness: Past history: Previous health status: well ordinary bad Infectious history: Allergic history: History of Trauma and surgery: Review of systems Respiratory system: Circulatory system: Alimentary system: Urinary system: Hematopoietic system: Endocrine system: Nervous system: Motor system： Personal history： Birth place: occupation: sexual history: Smoking: N Y about years average pieces per day stopped for years Alcohol intake: N Y about years average ml per day stopped for years Marital history: single married spouse’s state of health: well bad Menstrual and childbearing history: Menstrual period ( ) Menarche age( )---------------------------LMP or age of menopause( ) Menstrual cycle ( ) Menstrual cycle: regular irregular Amount of flow: litter normal large Menstrual pain: N Y Pregnancy: times natural labor: times abortion: times Premature delivery: times stillbirth: times Family history: Congenital disease: N Y ( ) Health status of parents:
Physical examination Vital sign T： ℃, P： /min, R： /min, BP： mmHg. General appearance Development: ortho-sthenic type asthenic type sthenic type Facial feature: normal acute chronic others Expression: natural painful anxious dreadful indifferent Position: active semi-recumbent other Consciousness: aware somnolence confusion stupor coma delirium Cooperation: well badly Skin and mucosa Color: normal red pale cyanosis yellow pigmentation Lesions: N Y (type and distribution ) Subcutaneous hemorrhage: N Y (type and distribution ) Hair: normal scattering losing(position ) Moisture and temperature: normal cold dry wet Elasticity: normal reduced Edema: N Y (position and degree ) Hepatic palm: N Y Spider angioma: N Y (position and degree ) Other: Superficial lymph node non-swelling swelling (position and characteristic ) Head Cranium size: normal large small Deformity: N Y (oxycephaly squared skull deforming skull ) Others: tenderness mass sunk (position ) Ear: Auricles: normal deformity fistula others (left right) Excretion of external auditory canals: N Y(left right feature ) Tenderness in mastoid area: N Y Auditory acuity: N Y (left right) Nose: Shape: normal abnormal Other abnormality: N Y (nasal ala flap obstruction excretions) Nasal sinus tenderness: N Y (position ) Eye: Eyelids: normal edema ptosis trichiasis Eyeballs: normal proptosis(left right) depression (left right) tremor motion dysfunction (left right) Conjunctiva: normal edema congestive hemorrhage Sclera:normal yellow Cornea: normal abnormal (left right) Pupils: equal roundness same size unequal (left cm right cm) Reactions to light: normal delay (left right) disappear (left right) Other: Mouth: Lips: red cyanosis pale herpes fissure Mucosa: normal abnormal (pale petechia others ) Tongue: normal abnormal (coverings hemorrhage leaning to left or right) Gums normal swelling pus overflow hemorrhage pigmentation lead line Tooth: regular edentulous carious teeth Tonsils: normal enlarged(degree ) Voice: normal hoarse Neck: Resistance: N Y Carotid artery pulsation: normal increased decreased(left right) Jugular vein: normal distention high distention Hepatojugular reflux: (-) (+) Trachea: middle deviation to (left right) Thyroid: normal symmetry swelling (degree ) dominance in L/R Spreading nodular: soft hard other: N Y（tenderness tremor bruits ）
Chest Topography: normal barrel chest flat chest pigeon chest funnel chest Bulging or retraction (left right) Tenderness of sternum: N Y Brest: normal symmetrical abnormal: left right(mass tenderness gynecomastia excretions of nipple) Lung Inspection movement of respiration : normal abnormal left right(increased decreased) intercostal space: normal wide narrow(position ) palpation Vocal fermitus: normal abnormal left right(increased decreased) pleural friction rubs: N Y (position ) subcutaneous crepitus: N Y (position ) percussion: resonance dullness flatness hyperresonance tympany lower borders: scapular line: right intercostal space range of mobility: right cm left cm auscultation： breath: regular irregular breath sound: normal abnormal(feature position ) rale: N Y ronchi: sonorous sibilant moist rales: coarse medium fine crepitus