医学英语病历

1.抗生素医嘱[Antibiotic order]

·Prophylaxis [预防性用药] Duration of oder[用药时间] 24hr

Procedure[操作，手术]

·Empiric theraphy [经验性治疗]

Suspected site and organism[怀疑感染的部位和致病菌] 72hr

Cultures ordered[是否做培养]

·Documented infection[明确感染]

Site and organism[部位和致病菌] 5days

·Other[其他]

Explanation required [解释理由] 24hr

·Antibiotic allergies[何种抗生素过敏]

No known allergy [无已知的过敏]

·Drug+dose+Route+frequency[药名+剂量+途径+次数]

2、医嘱首页[Admission / transfer]

·Admit / transfer to [收入或转入]

·Resident [住院医师] Attending[主治医师]

·Condition [病情]

·Diagnosis[诊断]

·Diet [饮食]

·Acitivity [活动]

·Vital signs[测生命体征]

·I / O [记进出量]

·Allergies[过敏]

3、住院病历[case history]

·Identification [病人一般情况]

Name[性名]

Sex[性别]

Age [年龄]

Marriage[婚姻]

Person to notify and phone No.[联系人及电话]

Race[民族]

I.D.No.[身份证]

Admission date[入院日期]

Source of history[病史提供者]

Reliability of history[可靠程度]

Medical record No[病历号]

Business phone No.[工作单位电话]

Home address and phone No.[家庭住地及电话]

·Chief complaint[主诉]

·History of present illness[现病史]

·Past History[过去史]

Surgical[外科]

Medical[内科]

Medications[用药]

Allergies[过敏史]

Social History[社会史]

Habits[个人习惯]

Smoking[吸烟]

Family History[家族史]

Ob/Gyn History[ 婚姻/生育史]

Alcohol use[喝酒]

·Review of Aystems[系统回顾]

General[概况]

Eyes,Ears,Nose and throat[五官]

Pulmonary[呼吸]

Cardiovascular[心血管]

GI[消化]

GU[生殖、泌尿系统]

Musculoskeletal[肌肉骨骼]

Neurology[神经系统]

Endocrinology[内分泌系统]

Lymphatic/Hematologic[淋巴系统/血液系统]

·Physical Exam[体检]

Vital Signs[生命体征]

P[脉博]

Bp[血压]

R[呼吸]

T[温度]

Height[身高]

Weight[体重]

General[概况]

HEENT[五官]

Neck[颈部]

Back/Chest[背部/胸部]

Breast[乳房]

Heart[心脏]

Heart rate[心率]

Heart rhythm[心律]

Heart Border[心界]

Murmur[杂音]

Abdomen[腹部]

Liver[肝]

Spleen[脾]

Rectal[直肠]

Genitalia[生殖系统]

Extremities[四肢]

Neurology[神经系统]

cranial nerves[颅神经]

sensation[感觉]

Motor[运动]

*Special P.E. on diseased organ system[专科情况]

*Radiographic Findings[放射]

*Laboratory Findings[化验]

*Assessment[初步诊断与诊断依据]

*Summary[病史小结]

*Treatment Plan[治疗计划]

4、输血申请单[Blood bank requisition form]

(1)reason for infusion[输血原因]

▲红细胞[packed red cells, wshed RBCs]:

*Hb<8.5 [血色素<8.5]

*>20% blood volume lost [>20%血

容量丢失]

*cardio-pulmonary bypass with anticipated Hb <8[心肺分流术伴预计血色素

<8]

*chemotherapy or surgery with Hb <10[血色素<10的化疗或手术者]

▲全血[whole blood]:

massive on-going blood loss[大量出血]

▲血小板[platelets]:

*massive blood transfusion >10 units[输血10单位以上者]

*platelet count <50×103/μl with active bleeding or surgery[血小板<5万伴活

动性出血或手术者]

*Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流

术伴血小板<10万，活动性出血者]

*Platelet count <20×103/μl[血板<2万]

▲新鲜冰冻血浆[fresh frozen plasma]:

*documented abnormal PT or PTT with bleeding or Surgery[PT、PTT异常的

出血或手术病人]

*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏

的出血/手术者]

*blood transfusion >15units[输血>15个单位]

*warfarin or antifibrinolytic therapy with bleeding[华法令或溶栓治疗后出血]

*DIC[血管内弥漫性凝血]

*Antithrombin III dficiency[凝血酶III 缺乏]

(2)输血要求[request for blood components]

*patient blood group[血型]

*Has the patient had transfusion or pregnancy in the past 3 months? [近3个月，

病人是否输过血或怀孕过？]

*Type and crossmatch[血型和血交叉]

*Units or ml[单位或毫升]

5、出院小结[discharge summary]

Patient Name[病人姓名]

Medical Record No.[病历号]

Attending Physician[主治医生]

Date of Admission[入院日期]

Date of Discharge[出院日期]

Pirncipal Diagnosis[主要诊断]

Secondary Diagnosis[次要诊断]

Complications[并发症]

Operation[手术名称]

Reason for Admission[入院理由]

Physical Findings[阳性体征]

Lab/X-ray Findings[化验及放射报告]

Hospital Course[住院诊治经过]

Condition[出院状况]

Disposition[出院去向]

Medications[出院用药]

Prognosis[预后]

Special Instruction to the Patient(diet, physical activity)[出院指导（饮食，活

动量）]

Follow-up Care[随随访]

6、住院/出院病历首页[Admission/discharge record]

·Patient name[病人姓名]

·race[种族]

·address[地址]

·religion[宗教]

·medical service[科别]

·admit (discharge) date[入院（出院）日期]

·Length of stay [住院天数]

·guarantor name [担保人姓名]

·next of kin or person to notify[需通知的亲属姓名]

·relation to patient[与病人关系]

·previous admit date[上次住院日期]

·admitting physician [入院医生]

·attending phgsician[主治医生]

·admitting diagnosis[入院诊断]

·final (principal) diagnosis[最终（主要）诊断]

·secondary diagnosis[次要诊断]

·adverse reactions (complications)[副作用（合并症）]

·incision type[切口类型]

·healing course[愈合等级]

·operative (non-operative) procedures[手术（非手术）操作]

·nosocomial infection[院内感染]

·consutants[会诊]

·Critical-No. of times[抢救次数]

·recovered-No. of times[成功次数]

·Diagnosis qualitative analysis[诊断质量]

OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率]

Clinical and pathological Dx concur[临床与病理诊断符合率]

Pre- and post-operative Dx concur [术前术后诊断符合率]

·Dx determined with in 24 hours (3 days) after admission[入院后24小时（3

天）内确诊]

·Discharge status[出院状况]

recovered[治愈]

improved[好转]

not improved[未愈]

died [死亡]

·Dispositon[去向]

home[家]

against medical ad[自动出院]

autosy[尸检]

transferred to[转院到]