手機版
1、抗生素醫(yī)囑[Antibiotic order]
•Prophylaxis [預(yù)防性用藥]
Duration of order[用藥時間] 24hr
Procedure[操作，手術(shù)]
•Empiric therapy [經(jīng)驗性治療]
Suspected site and organism[懷疑感染的部位和致病菌] 72hr
Cultures ordered[是否做培養(yǎng)]
•Documented infection[明確感染]
Site and organism[部位和致病菌] 5days
•Other[其它]
Explanation required [解釋理由] 24hr
•Antibiotic allergies[何種抗生素過敏]
No known allergy [無已知的過敏]
•Drug+ dose+ Route+ frequency[藥名+劑量+途徑+次數(shù)]
2、醫(yī)囑首頁[Admission / transfer]
•Admit / transfer to [收入或轉(zhuǎn)入]
•Resident [住院醫(yī)師] Attending[主治醫(yī)師]
•Condition [病情]
•Diagnosis[診斷]
•Diet [飲食]
•Activity [活動]
•Vital signs[測生命體征]
•I / O [記進出量]
•Allergies[過敏]
3、住院病歷[case history]
•Identification [病人一般情況]
Name[性名]
Sex[性別]
Age [年齡]
Marriage[婚姻]
Person to notify and phone No.[聯(lián)系人及電話]
Race[民族]
I.D. No.[身份證]
Admission date[入院日期]
Source of history[病史提供者]
Reliability of history[可靠程度]
Medical record No[病歷號]
Business phone No.[工作單位電話]
Home address and phone No.[家庭住地及電話]
•Chief complaint[主訴]
•History of present illness[現(xiàn)病史]
•Past History[過去史]
Surgical[外科]
Medical[內(nèi)科]
Medications[用藥]
Allergies[過敏史]
Social History[社會史]
Habits[個人習(xí)慣]
Smoking[吸煙]
Family History[家族史]
Ob/Gyn History[ 婚姻/生育史]
Alcohol use[喝酒]
•Review of Aystems[系統(tǒng)回顧]
General[概況]
Eyes, Ears, Nose and throat[五官]
Pulmonary[呼吸]
Cardiovascular[心血管]
GI[消化]
GU[生殖、泌尿系統(tǒng)]
Musculoskeletal[肌肉骨骼]
Neurology[神經(jīng)系統(tǒng)]
Endocrinology[內(nèi)分泌系統(tǒng)]
Lymphatic/Hematologic[淋巴系統(tǒng)/血液系統(tǒng)]
•Physical Exam[體檢]
Vital Signs[生命體征]
P[脈博]
Bp[血壓]
R[呼吸]
T[溫度]
Height[身高]
Weight[體重]
General[概況]
HEENT[五官]
Neck[頸部]
Back/Chest[背部/胸部]
Breast[乳房]
Heart[心臟]
Heart rate[心率]
Heart rhythm[心律]
Heart Border[心界]
Murmur[雜音]
Abdomen[腹部]
Liver[肝]
Spleen[脾]
Rectal[直腸]
Genitalia[生殖系統(tǒng)]
Extremities[四肢]
Neurology[神經(jīng)系統(tǒng)]
cranial nerves[顱神經(jīng)]
sensation[感覺]
Motor[運動]
*Special P.E. on diseased organ system[�？魄闆r]
*Radiographic Findings[放射]
*Laboratory Findings[化驗]
*Assessment[初步診斷與診斷依據(jù)]
*Summary[病史小結(jié)]
*Treatment Plan[治療計劃]
4、輸血申請單[Blood bank requisition form]
(1)reason for infusion[輸血原因]
▲紅細胞[packed red cells, wshed RBCs]:
*Hb<8.5 [血色素<8.5]
*>20% blood volume lost [>20%血容量丟失]
*cardio-pulmonary bypass with anticipated Hb <8[心肺分流術(shù)伴預(yù)計血色素<8]
*chemotherapy or surgery with Hb <10[血色素<10的化療或手術(shù)者]
▲全血[whole blood]:
massive on-going blood loss[大量出血]
▲血小板[platelets]:
*massive blood transfusion >10 units[輸血10單位以上者]
*platelet count <50×103/μl with active bleeding or surgery[血小板<5萬伴活動性出血或手術(shù)者]
*Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流術(shù)伴血小板<10萬，活動性出血者]
*Platelet count <20×103/μl[血板<2萬]
▲新鮮冰凍血漿[fresh frozen plasma]:
*documented abnormal PT or PTT with bleeding or Surgery[PT、PTT異常的出血或手術(shù)病人]
*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手術(shù)者]
*blood transfusion >15units[輸血>15個單位]
*warfarin or antifibrinolytic therapy with bleeding[華法令或溶栓治療后出血]
*DIC[血管內(nèi)彌漫性凝血]
*Antithrombin III dficiency[凝血酶III 缺乏]
(2)輸血要求[request for blood components]
*patient blood group[血型]
*Has the patient had transfusion or pregnancy in the past 3 months? [近3個月，病人是否輸過血或懷孕過？]
*Type and crossmatch [血型和血交叉]
*Units or ml[單位或毫升]
5、出院小結(jié)[discharge summary]
Patient Name[病人姓名]
Medical Record No.[病歷號]
Attending Physician[主治醫(yī)生]
Date of Admission[入院日期]
Date of Discharge[出院日期]
Principal Diagnosis[主要診斷]
Secondary Diagnosis[次要診斷]
Complications[并發(fā)癥]
Operation[手術(shù)名稱]
Reason for Admission[入院理由]
Physical Findings[陽性體征]
Lab/X-ray Findings[化驗及放射報告]
Hospital Course[住院診治經(jīng)過]
Condition[出院狀況]
Disposition[出院去向]
Medications[出院用藥]
Prognosis[預(yù)后]
Special Instruction to the Patient(diet, physical activity)[出院指導(dǎo)（飲食，活動量）]
Follow-up Care[隨隨訪]
6、住院/出院病歷首頁[Admission/discharge record]
•Patient name[病人姓名]
•race[種族]
•address[地址]
•religion[宗教]
•medical service[科別]
•admit (discharge) date[入院（出院）日期]
•Length of stay [住院天數(shù)]
•guarantor name [擔(dān)保人姓名]
•next of kin or person to notify[需通知的親屬姓名]
•relation to patient[與病人關(guān)系]
•previous admit date[上次住院日期]
•admitting physician [入院醫(yī)生]
•attending physician [主治醫(yī)生]
•admitting diagnosis[入院診斷]
•final (principal) diagnosis[最終（主要）診斷]
•secondary diagnosis[次要診斷]
•adverse reactions (complications)[副作用（合并癥）]
•incision type[切口類型]
•healing course[愈合等級]
•operative (non-operative) procedures[手術(shù)（非手術(shù)）操作]
•nosocomial infection[院內(nèi)感染]
•consultants [會診]
•Critical-No. of times[搶救次數(shù)]
•recovered-No. of times[成功次數(shù)]
•Diagnosis qualitative analysis[診斷質(zhì)量]
OP.adm.and discharge Dx concur [門診入院與出院診斷符合率]
Clinical and pathological Dx concur[臨床與病理診斷符合率]
Pre- and post-operative Dx concur [術(shù)前術(shù)后診斷符合率]
•Dx determined with in 24 hours (3 days) after admission[入院后24小時（3 天）內(nèi)確診]
•Discharge status[出院狀況]
recovered[治愈]
improved[好轉(zhuǎn)]
not improved[未愈]
died [死亡]
•Dispositon[去向]
home[家]
against medical ad[自動出院]
autosy[尸檢]
transferred to[轉(zhuǎn)院到]