病歷書寫的要領(lǐng)地區(qū)醫(yī)院協(xié)會(huì)研習(xí)會(huì)20xx1125~122-資料下載頁(yè)
2025-07-20 03:36本頁(yè)面
【正文】 re Note (一定要寫明時(shí)間 ) ? Procedure done: spinal tapping ? Indication: To rule out CNS infection。 eye ground showed no signs of increased ICP, and cranial CT showed no mass. ? Consent form obtained after thorough explanation to the patient in the presence of RN Chen YJ and the patient’s mother ? Patient was laid on his left lateral side in fetal position ? Local anesthesia with 2% Xylocain, 5 mL. ? 22 G spinal tap needle was inserted through the space between L3L4 without problem ? CSF, crystal clear, 2 mL each, was withdrawn into four tubes. One sent for antigen studies (…), culture, and smears。 one sent for chemistry。 one for cell counts。 and the last one for STS/VDRL. ? OP: 110 mmHg。 and CP: 100 mmHg ? There was no plication and the patient tolerated the procedures well. ? The patient was instructed to lie on his back for 8 hours. ? Simultaneous blood sugar has been drawn 給週末或假期接班人看的摘要 1. 簡(jiǎn)單扼要 2. 說(shuō)明這次住院經(jīng)過(guò) 3. 問(wèn)題解決的程度 4. 目前如何處理中 5. 這幾天內(nèi)有可能發(fā)生的問(wèn)題，要請(qǐng)值班醫(yī)師特別注意的問(wèn)題 6. 可聯(lián)絡(luò)到我的電話號(hào)碼 常見(jiàn)的病歷英文缺失 錯(cuò)誤的、或不恰當(dāng)?shù)牟v英文 (1) ? Cancer was told ?He was told that he has cancer。 He was diagnosed with cancer。 Cancer was suspected 或 diagnosed ?；? “ Cancer”, he was told.(小說(shuō)式的 ) ? The patient went to an Dr. Chen’s clinic in vain。 ?應(yīng)該寫 the treatment was not effective。 或 the symptoms did not improve . 錯(cuò)誤的、或不恰當(dāng)?shù)牟v英文 (2) ? The patient ever went to a hospital ? The patient has been to a hospital. The patient did go to a hospital. ? Acception note ?acceptance note, 或 on service note. ? Progression note， progressive note? progress note . ? Cancer was impressed? Cancer was suspected . 錯(cuò)誤的、或不恰當(dāng)?shù)牟v英文 (3) ? Conscious clear. ?Consciousness: alert, coherent and oriented as to time, place, and person (常簡(jiǎn)寫成 oriented x 3) ? Mentality clear ?應(yīng)該寫 consciousness… 。 ? The patient is anemia.? The patient is anemic 。 The patient has anemia. 錯(cuò)誤的、或不恰當(dāng)?shù)牟v英文 (4) ? Discharge diagnosis: R/O cancer ?probable cancer、 suspected cancer。 ? The patient developed abdominal pain and high fever , Abdominal pain and high fever developed .兩句都對(duì) !!! ? 會(huì)診單上寫完意見(jiàn)之後自己寫 Thank you for the consultation [???] ?只需寫 Thank you for the Thanks. ? Nothing particular. (N P) ? unremarkable。 錯(cuò)誤的、或不恰當(dāng)?shù)牟v英文 (5) ? Unfortunately （可免寫） , abdominal pain and high fever developed。 ? Dear Dr. 。 We sincerely request……。 your nationally reputable expertise…. Your globally acclaimed technical skills : ?都可免寫，多記載病史、檢驗(yàn)數(shù)據(jù)。 ? According to the statement of the patient? according to the patient。 according to his sister。 ? The patient is a victim of motor vehicle accident (MVA). ?可寫成 The patient had an MVA。 錯(cuò)誤的、或不恰當(dāng)?shù)牟v英文 (6) ? MBD (may be discharged) ? discharge。 discharge in AM。 ? AAD ? discharge against medical advice。 discharge AMA。 ? 臺(tái)灣病理報(bào)告 : nonmade (???) 。 對(duì)人處事的原則 誠(chéng)信 責(zé)任感 禮節(jié) 公德心 勤勉 致力於創(chuàng)意 我們需要加強(qiáng)培養(yǎng)： ?獨(dú)立思考的能力！！ ?老師鼓勵(lì)學(xué)生的創(chuàng)意！ ?上司、主管容忍不同的意見(jiàn)，客觀地討論！ ?學(xué)者間多交換意見(jiàn)！研討會(huì)多發(fā)言！ ?不吝讚賞別人的創(chuàng)意，不吝提供建設(shè)性的批評(píng)！ ? “這樣是不是可能比較好？” ?活到老，學(xué)到老的精神！ ?聞過(guò)則喜，有錯(cuò)就改！ 『 知錯(cuò)能改，善莫大焉！ 』
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