医学英语住院文书格式Word文档格式.docx
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医学英语住院文书格式Word文档格式.docx
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Procedure[操作,手术]
Empirictheraphy[经验性治疗]
Suspectedsiteandorganism[怀疑感染的部位和致病菌]72hr
Culturesordered[是否做培养]
Documentedinfection[明确感染]
Site andorganism[部位和致病菌]5days
Other[其他]
Explanation required[解释理由]24hr
Antibioticallergies[何种抗生素过敏]
Noknownallergy[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]
Vitalsigns[测生命体征]
I/O [记进出量]
Allergies[过敏]
3、住院病历[casehistory]
Identification[病人一般情况]
Name[性名]
Sex[性别]
Age[年龄]
Marriage[婚姻]
Personto notifyandphoneNo.[联系人及电话]
Race[民族]
I.D.No.[身份证]
Admissiondate[入院日期]
Sourceof history[病史提供者]
Reliabilityofhistory[可靠程度]
Medicalrecord No[病历号]
BusinessphoneNo.[工作单位电话]
Home addressand phoneNo.[家庭住地及电话]
Chiefcomplaint[主诉]
History ofpresentillness[现病史]
PastHistory[过去史]
Surgical[外科]
Medical[内科]
Medications[用药]
Allergies[过敏史]
SocialHistory[社会史]
Habits[个人习惯]
Smoking[吸烟]
FamilyHistory[家族史]
Ob/GynHistory[婚姻/生育史]
Alcoholuse[喝酒]
ReviewofAystems[系统回顾]
General[概况]
Eyes,Ears,Nose andthroat[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]
PhysicalExam[体检]
VitalSigns[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]
Heartrate[心率]
Heartrhythm[心律]
HeartBorder[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]
*SpecialP.E.ondiseasedorgansystem[专科情况]
*Radiographic Findings[放射]
*LaboratoryFindings[化验]
*Assessment[初步诊断与诊断依据]
*Summary[病史小结]
*TreatmentPlan[治疗计划]
4、输血申请单[Bloodbankrequisitionform]
(1)reasonfor infusion[输血原因]
红细胞[packedredcells,wshedRBCs]:
*Hb20% bloodvolume lost[>
20%血容量丢失]
*cardio-pulmonarybypass with anticipatedHb 10 units[输血10单位以上者]
*plateletcount15units[输血>
15个单位]
*warfarinor antifibrinolytic therapywithbleeding[华法令或溶栓治疗后出血]
*DIC[血管内弥漫性凝血]
*AntithrombinIIIdficiency[凝血酶III缺乏]
(2)输血要求[requestforbloodcomponents]
*patientbloodgroup[血型]
*Has the patienthadtransfusion orpregnancyinthepast3months[近3个月,
病人是否输过血或怀孕过?
]
*Typeand crossmatch[血型和血交叉]
*Unitsor ml[单位或毫升]
5、出院小结[dischargesummary]
PatientName[病人姓名]
MedicalRecordNo.[病历号]
AttendingPhysician[主治医生]
DateofAdmission[入院日期]
Dateof Discharge[出院日期]
Pirncipal Diagnosis[主要诊断]
SecondaryDiagnosis[次要诊断]
Complications[并发症]
Operation[手术名称]
Reasonfor Admission[入院理由]
Physical Findings[阳性体征]
Lab/X-rayFindings[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]
SpecialInstruction tothe Patient(diet, physicalactivity)[出院指导(饮食,活动量)]
Follow-upCare[随随访]
6、住院/出院病历首页[Admission/dischargerecord]
Patientname[病人姓名]
race[种族]
address[地址]
religion[宗教]
medicalservice[科别]
admit(discharge) date[入院(出院)日期]
Length of stay[住院天数]
guarantorname[担保人姓名]
nextof kinorpersonto notify[需通知的亲属姓名]
relationtopatient[与病人关系]
previousadmitdate[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]
secondarydiagnosis[次要诊断]
adversereactions(complications)[副作用(合并症)]
incisiontype[切口类型]
healing course[愈合等级]
operative(non-operative) procedures[手术(非手术)操作]
nosocomialinfection[院内感染]
consutants[会诊]
Critical-No.of times[抢救次数]
recovered-No.oftimes[成功次数]
Diagnosisqualitativeanalysis[诊断质量]
OP.adm.anddischargeDxconcur [门诊入院与出院诊断符合率]
Clinical andpathological Dx concur[临床与病理诊断符合率]
Pre-and post-operativeDx concur[术前术后诊断符合率]
Dx determinedwithin 24hours(3days)afteradmission[入院后24小时(3天)内确诊]
Dischargestatus[出院状况]
recovered[治愈]
improved[好转]
notimproved[未愈]
died [死亡]
Dispositon[去向]
home[家]
against medicalad[自动出院]
autosy[尸检]
transferredto[转院到]
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