《病历书写英文》由会员分享，可在线阅读，更多相关《病历书写英文（43页珍藏版）》请在金锄头文库上搜索。
1、lHISTORY RECORDWhat is history recordWhat is history recordlThe clinical record documents the patients history and physical findings. It shows how clinicians assess the patient, what plans they make on the patients behave, what actions they take, and how the patient responds to their efforts .Import
2、ance of history recordImportance of history recordl1. Diagnosis and treatment purposeAn accurate, clear, well organized record reflects and facilitates sound clinical thinking. It leads to good communication among the many professionals who participate in caring for the patient l2. Teaching and rese
3、arch purposel3. Medicolegal purposes How to make a good historyHow to make a good historyrecordrecordlWhen creating a record, you do more than simply make a list of what the patient has told you and what you have found on examination. You must review your data, organize them, evaluate the importance
4、 and relevance of each item, and construct a clear, concise, yet comprehensive report. How to make a good historyHow to make a good historyrecordrecordl1. Order is imperativel2. Keep items of history in the history l3. Describe specifically any pertinent negative information l4. Data not recorded ar
5、e data lost l5. Use short words instead of long and probably fancier ones when they mean the same thing l6. Be objectivel7. You should write the record as soon as possible Basic requirement for theBasic requirement for thehistory recordhistory recordl1. To be well organized and canonicall2. No much
6、erasion and gride could be done in the history recordl3. To be objective and accuratel4. Using professional term to record instead of folksayl5. Remember to have your signatureA. Outline of case recordA. Outline of case recordl1. Biographical data Biographical information of patient should include h
7、is full name, age (date of birth), sex, race, occupation, nationality, marital status and permanent home address. Also, the date of admission, the time at which you took the history, the source of history and estimate of reliability should be involved.l2. chief complaint The chief complaint consists
8、 of main symptom(s) and duration. It should constitute in a few simple words the main reasons why the patient consulted doctor and should be state as nearly as possible in the patients own wards. In general, the chief complaint should include age, sex, complaint, and duration of the complaint. It sh
9、ould no included diagnostic terms or disease entities. For example:” This 70-year old man has had short breath for a week.”l3. History of present illness (HPI) The history of present ill ness should be a well-organized, sequentially developed elaboration of his chief complaint(s) on its various char
10、acteristics: date of onset, character of complaint, mode of onset, course and duration, location, relationship to other symptoms, bodily function and activities, exacerbation and remissions, and effect of treatment.l4. Past history (PH) It should include a review of all past ill nesses, surgical pro
11、cedures, and injuries, and allergy history (medicine, food), which are particularly related to the present illness.l5. Review of system (ROS) The purpose of sys tem review is twofold: a thorough evaluation and a double check prevent omission of significant data relative to the present illness. The r
12、eview is a comprehensive account of all complaints referable to each body system progressing in a logical manner from the head toward the feet, including respiratory system, cardiovascular system, digestive system, Urinary system, hemopoietic system, endocrine system, nervous system and skeletal sys
13、tem.l6. Personal history (social and occupational history) It includes personal habits (smoking, alcohol drinking), business life, sex life, occupation (exposure to certain irritating agents), condition of work.l7. Marital history It includes data concerning the health of mate, sexual adjustment, th
14、e number of children and their Physical status, and the general social adjustment within the family.l8. Menstrual history ( for female patients) Age of onset, interval between periods, duration, amount and character of flow, concomitant symptoms, date of last menstruation, age of menopause.l9. Child
15、bearing (reproductive) history Age and date of pregnancy(ies) and childbirth(s). Date of artificial or natural abortions, stillbirths, operative delivery, puerperal fever. Method of family planning, the possible factors of infertility (also for male patients).l10. Family history (FH) The health stat
16、us of the patients family (mother, father, siblings and children) and if died, the age and cause of death should be recorded, such as diabetes, hypertension, cancer, obesity, allergic disorders, coronary artery disease and mental illness.l11. Physical examination (PE) The recording of Physical examination should follow a logical sequence as follows: vital signs, general status, skin, nodes, head, neck, chest, lungs, heart and blood vessels, abdomen, genitalia, rectum, spin
