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1、1、 抗生素医嘱Antibiotic orderProphylaxis 预防性用药 Duration of oder用药时间 24hrProcedure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 72hrCultures ordered是否做培养Documented infection明确感染Site and organism部位和致病菌 5daysOther其他Explanation required 解释理由 24hrAntibiotic allergies何种抗生素过敏No known allergy
2、 无已知的过敏Drug+dose+Route+frequency药名+剂量+途径+次数2、医嘱首页Admission / transferAdmit / 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 historyIdentification 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
3、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
4、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H
5、EENT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
6、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:*Hb8.5 血色素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 units输血10单位以上者*platelet count 50103/
7、l with active bleeding or surgery血小板5万伴活动性出血或手术者*Cardio-pulmonary bypass uith pl100103/l with octive bleeding心肺分流术伴血小板10万，活动性出血者*Platelet count 20103/l血板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 bloo
8、d 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 summaryPatient 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 Dia
9、gnosis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/
10、出院病历首页Admission/discharge recordPatient 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admitt
11、ing 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 qualita
12、tive 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转院到医学英语常用前后缀医学英语常用前后缀 a-无，缺 anemia贫血 atonia无张力 asymptomatic无症状的 amenorrhea闭经 ab-分离 abduct 外展 abscision切除 acou (acu)-听觉 acumeter 听力计 acouophone助听器 acro-肢端 acromegaly肢端肥大症 acromastitis乳头炎 ad (af, an)-邻近，向
