1、抗生素醫(yī)囑[Antibiotic order]
Prophylaxis [預(yù)防性用藥]
Duration of order[用藥時(shí)間] 24hr
Procedure[操作，手術(shù)]
Empiric therapy [經(jīng)驗(yàn)性治療]
Suspected site and organism[懷疑感染的部位和致病菌]
Cultures ordered[是否做培養(yǎng)]
Documented infection[明確感染]
Site and organism[部位和致病菌]
Other[其它]
Explanation required [解釋理由]
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(jìn)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(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]
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]l
P[脈博]
Bp[血壓]
R[呼吸]
T[溫度]
Height[身高]
Weight[體重]
General[概況]l
HEENT[五官]
Neck[頸部]
Back/Chest[背部/胸部]
Breast[乳房]
Heart[心臟]l
Heart rate[心率]
Heart rhythm[心律]
Heart Border[心界]
Murmur[雜音]
Abdomen[腹部]l
Liver[肝]
Spleen[脾]
Rectal[直腸]
Genitalia[生殖系統(tǒng)]
Extremities[四肢]l
Neurology[神經(jīng)系統(tǒng)]
cranial nerves[顱神經(jīng)]
sensation[感覺]
Motor[運(yùn)動]
Special P.E. on diseased organ system[?？魄闆r]
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]
4、輸血申請單[Blood bank requisition form]
(1)reason for infusion[輸血原因]
▲紅細(xì)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 [心肺分流術(shù)伴預(yù)計(jì)血色素 ]
*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/μlwith 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 orSurgery[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(gè)單位]
*warfarin or antifibrinolytic therapy withbleeding[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(gè)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]l
Medical Record No.[病歷號]l
Attending Physician[主治醫(yī)生]l
Date of Admission[入院日期]l
Date of Discharge[出院日期]l
Principal Diagnosis[主要診斷]l
Secondary Diagnosis[次要診斷]l
Complications[并發(fā)癥]l
Operation[手術(shù)名稱]l
Reason for Admission[入院理由]l
Physical Findings[陽性體征]l
Lab/X-ray Findings[化驗(yàn)及放射報(bào)告]l
Hospital Course[住院診治經(jīng)過]l
Condition[出院狀況]l
Disposition[出院去向]l
Medications[出院用藥]l
Prognosis[預(yù)后]l
Special Instruction to the Patient(diet,physical activity)[出院指導(dǎo)（飲食，活動量）]l
Follow-up Care[隨隨訪]l
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 the 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) afteradmission[入院后24小時(shí)（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]
