原汁原味的英文病历书写总结--最终版

2011/6/3YUHONGYANEnglishmedicalrecordswriting1/13【前言】：病历的书写，不管情不情愿，是我们见习、实习生活中十分重要的一部分。中文病历是基本要求，英文病历是附加题。对于书写英文病历，首先要明确自己的目的和期望。比如说通过书写英文病例学习专业词汇，与国际接轨；将来考虑出国；好奇心使然等等。有此意愿的同学大可好好思考一下，给自己一个理由和动力。协和有写英文病历的传统，但还没有统一、固定的格式。不过格式不外乎：国外原版和中文病例对译版。目前黄老师坚持，如果我们要写英文病历，就要跟国际化的要求接轨，所以支持原格式和写作习惯。但具体格式，都因医院、因人而异。故总结中注重的是—提出基本框架，规范术语。大家可作适合自己的微调。ACOMPLETEHistory&PhysicalHISTORYDateandTimeofhistory:IdentifyingData：Sourceofhistory,sourceofreferral:Reliability:Chiefcomplaints:quotethepatient’scomplaints,like“MystomachhurtsandIfeelawful”;orreporttheirgoals,like“Ihavecomeformyregularcheck-up”;[BATES’]patient’sage,abriefbutrelevantpastmedicalhistory,afewwordsaboutwhatproblembringsthepatienttothehospital(preferablequotethepatient),andduration[Writingahistory&physical]e.g.34-year-oldmalewithadvancedAIDScomplainsofa”badcough”andfeversoverthelast8days.56-year-oldmalewithahistoryofulcerativecolitiscomplainsof3monthsofworseningbackstiffness,2weeksof“asoreonmyleg”,and3daysoffeversandbloody,painlessdiarrhea.HistoryofPresentillness:fullsentencesinchronologicalmannerbedescriptivenotanalyticincludingthesetting,onsetoftheproblem,themanifestationandthetreatment.SevenAttributesofASymptom:location,quality,quantityorseverity,timing(onset,duration,frequency),thesettinginwhichtheyoccur,factorsthathaveaggravatedorrelievedthesymptom,associatedmanifestations.Pertinentpositives&pertinentnegativesPastMedicalHistoryChildhoodillnesses,suchasmeasles,rubella,mumps,whoopingcough,chickenpox,rheumaticfever,scarletfever(猩红热),polioetc.Adultdisease,infourcategories:Medical,suchas:diabetes,hypertension,hepatitis,asthma,andHIVetc.Surgical,suchas:trauma,operation(date,type);Ob/Gyn:Menstruationhistory(ageatmenarche,lastmenstruationperiod/ageatmenopause,menstrualcycle,menstrualperiod)Obstetrichistory(G_P_,pregnancy、deliveryandcomplications,)Sexualfunction;Methodofbirthcontrol,suchasoralcontraceptives,condoms,intrauterinering;2011/6/3YUHONGYANEnglishmedicalrecordswriting2/13Psychiatric;HealthmaintenanceImmunization(historyandrecentimmunization);Screeningtest,suchastuberculintest,Papsmear,mammogram,stooltestforoccultblood,cholesteroltestetc.Medication:name,dose,routeofadministration,interval.Noteforrecentcessationorchange;Allergy:Listthesubstanceandthereaction.Allergyvsintolerance;NOTE:药物过敏史与烟酒违禁药物使用分开。关于药物史和过敏史的位置，一共可以出现在两个地方：现病史，药物、过敏史。关于烟酒违禁药物使用，可以出现在现病史和个人史中。英文病历中现病史尽量详尽，如果相关，都应该放入现病史中。FamilyHistoryListordiagrameachimmediaterelative(age,health,majorillnessorcauseofdeath).Similarconditionamongfamilymembers;Presenceornot:Infectiousdisease,suchashepatitis,tuberculosis,STD;Complexdiseasewithahereditarytrend,suchasHTN,DM,CAD,elevatedcholesterollevel,stroke,cancer(specifytype),arthritis,asthma,headache,seizure,mentalillness,allergiesetc.PersonalandSocialHistory:[writteninfragments]Importantlifeexperiencesinchronologicalmanner:Birth,growthanddevelopment,educationlevel(militaryexperience),jobhistory(withorwithoutradiationortoxincontatct),retirement;sexualandMaritalhistory;Sourceofstress,religiousaffiliationandspiritualbeliefs;Tobacco(packperyear)/alcohol/drug(illicit)abuse:Lifestylehabits:Exerciseanddiet--FoodintoleranceSafetymeasuressuchasuseofseatbelts,bicyclehelmets,sunblocketc.Activitiesofdailyliving(ADLs),especiallyimportantinelderlypatients.ReviewofSystems(ROS)2011/6/3YUHONGYANEnglishmedicalrecordswriting3/13NOTE:系统回顾中描述的是近期出现或尚处于活动期的疾病或症状，而非很久以前发生的。它的目的是尽量详尽和全面，避免漏掉与现病不相关而忽视的症状、疾病。本部分明确的任何问题，都需要在小结和诊疗计划中作进一步的阐述。在ROS中明确的问题，与现病相关的应放在现病史，既往重大健康事件应放在既往史。General:Usualweight,recentweightchange.Weakness,fatigue,orfever.Skin:drynessorsweating;changesincolor;(regional)Rashes,lumps(肿块),sores,itching;changesinsizeorcolorofmoles(痣);changesinhairornails;Head,Eyes,Ears,Nose,Throat(HEENT):Head:Headache,dizziness,lightheadedness,headinjuryEyes:Visualacuity(视力,glassesorcontactlenses,lastexamination),visualfields[spots(点),specks(斑)],doubleorblurredvision,flashinglights,pain,redness,excessivetearing;historyofglaucoma,cataracts;Ears:hearing(excellentorimpaired,hearingaids?),tinnitus(耳鸣),vertigo(眩晕),earaches(耳痛),infection,discharge;Noseandsinuses:;nasalstuffiness(不通气),discharge,oritching,nosebleeds;Frequentcolds,hayfever;sinustrouble(tenderness);Throat(ormouthandpharynx):gums(bleedinggums);teeth[dentures(牙托),ifany,andhowtheyfit],lastdentalexamination;soretongue;drymouth;frequentsorethroats;hoarseness(声嘶);Neck:lumps;pain,orstiffnessintheneck;goiter;Breasts:Lumps,pain,ordiscomfort;nippledischarge;self-examinationpractices;Respiratory:Cough,sputum(color,quantity),hemoptysis,dyspnea,wheezing.Lastchestx-ray.Historyofasthma,bronchitis,emphysema,pneumonia,andtuberculosis,pleurisy.Cardiovascular:palpitations,chestpainordiscomfort,dyspnea,cyanosis,orthopnea(端坐呼吸),paroxysmalnocturnaldyspnea(夜间阵发性呼吸困难),lowerextremitiesedema,syncope.Positiveresultsofpastelectrocardiogramsorothercardiovasculartests.Historyofhighbloodpressure,rheumaticfever,heartmurmurs;Gastrointestinal:anorexia(lossofappetite),troubleswallowing,heartburn,excessivebelching(嗳气),nausea,vomiting,hematem