病历书写重点

CaseHistoryIn-PatientCaseHistory住院病历ItemsofCaseHistory1.GeneralData,BiographicalData一般项目2.ChiefComplaints(C.C.)主诉3.PresentIllness(P.I.)现病史4.Past(Medical)History(P.H.)既往病史5.PersonalHistory(Per.H.)/SocialHistory个人史/社会史6.FamilyHistory(F.H.)家族史7.Medications曾用药物8.Allergies过敏史9.SystemReview,ReviewofSystems系统回顾10.PhysicalExamination(P.E.)体格检查/查体11.LaboratoryData实验室与其他检查/检查资料12.Impression(Imp.)(Diagnosis)诊断13.HospitalCourse住院治疗情况记录14.DischargeInstructions/Recommendations出院医嘱15.DischargeMedications出院后用药GeneralData,BiographicalData一般项目Reliability(病历可靠性):Reliable(可靠)/NotEntirely(不完全可靠)/NotClearlyDefined(不够准确)/ConfusedandUncertain(混乱不清)/Unobtainable(无法获得)Supplier/ComplainerofHistory(供史者/病史陈述者):Patient/Husband/Wife/Father/Mother/Colleague/NeighborChiefComplaints(C.C.)主诉LanguageCharacteristics1)Commonexpressions①symptom+since+time(时间点)②symptom+for+time(时间段)③symptom+of+time(时间段名词所有格)+duration④symptom+time(时间段)+induration⑤time(时间段合成词)+history+of+symptom⑥completesentence:Thedurationof+symptom+was/hasbeen+time(时间段)（少见）2)Commonsentencepatternsforchiefcomplaints①…wasadmitted/seenwithachiefcomplaintof…②…complainchieflyof…③…presented/enteredwith/cametotheofficewithachiefcomplaintofExample主诉：患者是一个48岁的妇女。入院主诉，6个月来，出力后心悸和呼吸困难。CHIEFCOMPLAINT:Thepatientisa48-year-oldfemale,admittedwiththechiefcomplaintofpalpitationanddyspneafollowingphysicalexertionfor6months.HistoryofPresentIllness现病史LanguageCharacteristics1)SentencePatternswithPatientstoBeSubject以病人做主语的句型①starthaving开始有……的症状②beginhavingepisodesof…开始发生……的症状/疾病③become…变得……④notice(perceive,note,recognize…)+症状/疾病⑤have…有……症状/疾病⑥haveabrupt/sudden/explosiveonsetof…突然患……⑦haveepisodeof…/haveattackof…患……⑧develop+disease出现/有了……症状/疾病⑨…are/istheprodromeof………的前驱症状2)Sentencewithsymptoms,illnessesassubjects以症状、疾病做主语的句型①begin(occur,start…)+time从……开始②date(goback)to+time可追溯到……③bepresent+time在/从……已存在④beprecededby…在……之前已有⑤befollowedby…在……之后紧接着发生⑥beaccompaniedby…/coincidewith…与……同时发生⑦be(not)relatedto…/have(no)correlationwith…与……有（无）关3)Illness’improvingandworsening表达疾病的好转与恶化①last+time持续……时间②takeabadturn;takeaturnfortheworse;beaggravated/exacerbated;becomeworse恶化③takeagoodturn/takeaturnforthebetter/improve好转④beaggravated/abated/alleviatedby…因……而加剧/减轻⑤remainthesame/unchanged无变化⑥be(not)improvedaftertreatmentwith…经用……治疗而（无）好转⑦(Thesymptom)cease/cleanup/disappear/subside症状消失/减退4)Nosymptoms没发生……症状、疾病①…without/withno/freeof…(symptoms)②Therebenohistoryof…/…havenohistoryof…③(Thepatient)denies…④(Thepatient)notedno…⑤(Thepatient)wasnotfoundtobe…5)Descriptionofmainsymptoms描述主要症状①…assumethecharacterof/becharacterizedby…②…have/present/develop/show/manifestthesymptomsof…Past(Medical)History(P.H.)既往病史Commonexpressions①hadbeensound/welluntil;hadenjoyedgoodhealthuntil…在……前一直健康②beapt/liable/subjectto…;tendtohave…易患……③…wasadmittedtohospitalfor…/…washospitalizedfor…曾因……而住院④…had(someillness)withrecoveryafter…曾有（疾病），因…痊愈⑤…wasdiagnosedas…/…wassuspiciousof…断为……/疑为……⑥…wasexposedto(toxicsubstances)/…hadtobreathe(poisoninggases)接触/吸入⑦…wasinoculatedagainst…接种过……⑧…wasdischarged/dismissedfromhospital…/…wasoutofhospital…出院PersonalHistory(Per.H.)/SocialHistory个人史/社会史CharacteristicsoflanguageDeclarativesentencesandellipticalsentencesareusuallyused,andpresenttense,pasttenseandpastperfecttenseareadopted.FamilyHistory(F.H.)家族史Commonexpressions①…belivingandwell./…beingoodhealth./…bewellwithnoevidenceof(illness).健在②(Thereis)Nofamilyhistoryof(disease)./(Therewas)No(disease)inone’sfamily.无（病）家族史③Therewasnocaseof(disease)inhis//herfamily./Nooneinhis/herfamilyexperienced(disease)家族成员未曾患过……④Familyhistoryshowed/revealed…家族史显示……⑤Therewasafamilial/hereditarytendencyto…/Therewasastrongfamilyhistoryof…/Therewasahighincidenceof…inthefamily.家族有……倾向/发病率⑥Therewasahighprevalenceof…inthefamily家族中……患病率高⑦Positivefor(somedisease)in(someone).曾患过……⑧…asafamilycharacteristic.家族特点⑨FH:Noncontributory家族史无意义Allergies过敏史Commonexpressions①NKDA(noknowndrugallergies)无过敏史②allergy,allergic,hypersensitive,hypersensitivity过敏③sensitive,sensitivity,sensible,sensibility敏感④allergicreaction过敏反应⑤beallergicto…对……过敏⑥besensibleto…对……敏感⑦havenohistoryofallergyto…;havenohistoryof…sensibility对……有（无）过敏史⑧haveanallergicdiathesis具有过敏体质⑨havenoallergicreactiontoanydrugs对用过的药物无过敏反应⑩showsensibilityto…(e.g.housedust)对……（如室内灰尘）过敏PhysicalExamination(P.E.)体格检查，查体1)Physicaldata/physicalsigns一般资料/生理指标2)Generalappearance一般情况或全身状态3)Head,eyes,ear,noseandthroat(HEENT)头眼与耳鼻喉4)Chest,heartandlungs胸部与心肺5)Abdomen腹部6)Extremities四肢7)Nervoussystem,neurological(CNS/Neuro)神经系统8)Musculoskeletal骨骼肌肉系统9)Genitourinary泌尿生殖系统Physicaldata/physicalsigns一般资料/生理指标①Temperature(T.)体温position:oraltemperature口温；axillarytemperature腋温；rectaltemperature肛温unit:Celsius,℃;Fahrenheit,℉Format:T38℃(or100.4℉)②Pulse(P.)脉搏Format:P80/min(orP80)Pattern:Pulse80perminute.Thepulsenumbered/beat/measured80/min.③Respiration/RespiratoryRate(R.)呼吸Format:R20/minCommonexpressions:Therespirationsare21perminute.呼吸每分钟21次。④BloodPressure(B.P.)血压Format:BP16/10.5kpa血压16/10.5千帕BP150/95mmHg血压150/95毫米汞柱BPstabilizesat…kpa(mmHg)血压稳定在……千帕（毫米汞柱）BPfluctuates/ran