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    病歷文書常用基本用語

    放大字體  縮小字體 發(fā)布日期:2011-08-01
    核心提示:醫(yī)囑、住院/出院病歷的基本用語。


    1、抗生素醫(yī)囑[Antibiotic order]
    •Prophylaxis [預防性用藥]
    Duration of order[用藥時間] 24hr
    Procedure[操作,手術]
    •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[專科情況]
    *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[心肺分流術伴預計血色素<8]
    *chemotherapy or surgery with Hb <10[血色素<10的化療或手術者]
    ▲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者]
    *Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流術伴血小板<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異常的出血或手術病人]
    *specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手術者]
    *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[預后]
    Special Instruction to the Patient(diet, physical activity)[出院指導(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(非手術)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 [術前術后診斷符合率]
    •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]
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    關鍵詞: 住院 出院 病歷 常用語
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