醫(yī)學(xué)英語——住院文書格式.txt會計說：“你晚點來領(lǐng)工資吧，我這沒零錢。”你看得出我擦了粉嗎？雖然你身上噴了古龍水，但我還是能隱約聞到一股人渣味兒。既宅又腐，前途未卜。既宅又腐，前途未卜。你被打胎后是怎么從垃圾桶里逃出來的?史上最神秘的部門：有關(guān)部門。不可否認，馬賽克是這個世紀阻礙人類裸體藝術(shù)進步最大的障礙！1、抗生素醫(yī)囑[Antibioticorder]Prophylaxis[預(yù)防性用藥]Durationofoder[用藥時間]24hrProcedure[操作，手術(shù)]Empirictheraphy[經(jīng)驗性治療]Suspectedsiteandorganism[懷疑感染的部位和致病菌]72hrCulturesordered[是否做培養(yǎng)]Documentedinfection[明確感染]Siteandorganism[部位和致病菌]5daysOther[其他]Explanationrequired[解釋理由]24hrAntibioticallergies[何種抗生素過敏]Noknownallergy[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/transferto[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]Vitalsigns[測生命體征]I/O[記進出量]Allergies[過敏]3、住院病歷[casehistory]Identification[病人一般情況]Name[性名]Sex[性別]Age[年齡]Marriage[婚姻]PersontonotifyandphoneNo.[聯(lián)系人及電話]Race[民族]I.D.No.[身份證]Admissiondate[入院日期]Sourceofhistory[病史提供者]Reliabilityofhistory[可靠程度]MedicalrecordNo[病歷號]BusinessphoneNo.[工作單位電話]HomeaddressandphoneNo.[家庭住地及電話]Chiefcomplaint[主訴]Historyofpresentillness[現(xiàn)病史]PastHistory[過去史]Surgical[外科]病人是否輸過血或懷孕過？]*Typeandcrossmatch[血型和血交叉]*Unitsorml[單位或毫升]5、出院小結(jié)[dischargesummary]PatientName[病人姓名]MedicalRecordNo.[病歷號]AttendingPhysician[主治醫(yī)生]DateofAdmission[入院日期]DateofDischarge[出院日期]PirncipalDiagnosis[主要診斷]SecondaryDiagnosis[次要診斷]Complications[并發(fā)癥]Operation[手術(shù)名稱]ReasonforAdmission[入院理由]PhysicalFindings[陽性體征]Lab/X-rayFindings[化驗及放射報告]HospitalCourse[住院診治經(jīng)過]Condition[出院狀況]Disposition[出院去向]Medications[出院用藥]Prognosis[預(yù)后]SpecialInstructiontothePatient（diet，physicalactivity）[出院指導(dǎo)（飲食，活動量）]Follow-upCare[隨隨訪]6、住院/出院病歷首頁[Admission/dischargerecord]Patientname[病人姓名]race[種族]address[地址]religion[宗教]medicalservice[科別]admit（discharge）date[入院（出院）日期]Lengthofstay[住院天數(shù)]guarantorname[擔保人姓名]nextofkinorpersontonotify[需通知的親屬姓名]relationtopatient[與病人關(guān)系]previousadmitdate[上次住院日期]admittingphysician[入院醫(yī)生]attendingphgsician[主治醫(yī)生]admittingdiagnosis[入院診斷]final（principal）diagnosis[最終（主要）診斷]secondarydiagnosis[次要診斷]adversereactions（complications）[副作用（合并癥）]incisiontype[切口類型]healingcourse[愈合等級]operative（non-operative）procedures[手術(shù)（非手術(shù)）操作]nosocomialinfection[院內(nèi)感染]consutants[會診]Critical-No.oftimes[搶救次數(shù)]recovered-No.oftimes[成功次數(shù)]Diagnosisqualitativeanalysis[診斷質(zhì)量]OP.adm.anddischargeDxconcur[門診入院與出院診斷符合率]ClinicalandpathologicalDxconcur[臨床與病理診斷符合率]Pre-andpost-operativeDxconcur[術(shù)前術(shù)后診斷符合率]Dxdeterminedwithin24hours（3days）afteradmission[入院后24小時（3天）內(nèi)確診]Dischargestatus[出院狀況]