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您現(xiàn)在的位置: 醫(yī)學(xué)全在線 > 醫(yī)學(xué)英語(yǔ) > 英語(yǔ)教學(xué) > 英文病歷 > 正文:住院文書格式[Admission document]
    

住院文書格式,英文英語(yǔ)醫(yī)學(xué)

1、抗生素醫(yī)囑[Antibiotic order]
•Prophylaxis [預(yù)防性用藥]     Duration of oder[用藥時(shí)間]   24hr
  Procedure[操作,手術(shù)]
•Empiric theraphy [經(jīng)驗(yàn)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[其他]
  Explanation required [解釋理由]                          24hr
•Antibiotic allergies[何種抗生素過(guò)敏]
  No known allergy [無(wú)已知的過(guò)敏]
•Drug+dose+Route+frequency[藥名+劑量+途徑+次數(shù)]
2、醫(yī)囑首頁(yè)[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]
•Acitivity [活動(dòng)]
•Vital signs[測(cè)生命體征]
•I / O [記進(jìn)出量]
•Allergies[過(guò)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(hào)]
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(guò)去史]
  Surgical[外科]              
  Medical[內(nèi)科]
  Medications[用藥]         
  Allergies[過(guò)敏史]
  Social History[社會(huì)史]      
  Habits[個(gè)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]               醫(yī)學(xué)全在線www.med126.com
  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(yùn)動(dòng)]   
*Special P.E. on diseased organ system[專科情況]
*Radiographic Findings[放射]    
*Laboratory Findings[化驗(yàn)]
*Assessment[初步診斷與診斷依據(jù)]  
*Summary[病史小結(jié)]
*Treatment Plan[治療計(jì)劃]

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