入院录与病程录写作.pdf

第章 入院录与病程录写作 第章 入院录与病程记录 在临床实践中，记录病人发病与接受诊治过程中的临床事物，称为治疗记录。在欧美国家的医院里，传统的诊疗记录追求完整性，缺乏实用性。所以 Lawrence Weed.MD.于 1964年在Ir J Med Sci.期刊上发表文章“Medical records,patient care,and medical education”，提出应该以解决病人健康问题为核心的诊疗记录记录系统（Problem Oriented Medical Record，POMR），并在 Foster G.McGaw Hospital 予以实施。当时有人对此极力反对，认为过于烦琐。大量实践证明 POMR 是一客观有效仔细记录诊疗过程的方法。POMR 的基本成分包括：1.基本资料（Data Base）-病史、体检与实验室 2.完整问题列单（Complete Problem List）3.初步计划（Initial Plans）4.每日病程录（Daily Progress Note）5.出院小结（Final Progress Note or Discharge Summary）其中，第 1-3 个成分相当于中国医院的大病历，而大病历的简化形式称为入院录（Admission Note）。本篇介绍比较实用的临床诊疗记录方法：入院录、病程录与大病历，并重点介绍入院录的英文撰写方法。第一节 入院录“十点写作法”一.名称 入院录（Admission Note）其实是入院大病历的缩略形式。因为英语查房的最初环节就是由实习生报告简要病史，所以教学英文撰写入院录方法有其实际意义。与入院录类似的还有 History Digest of Clinical Case（临床病历摘要）、Presentation of Case History（病史陈述）与 Brief Case（简要病史）。但前后 2 类区分在于，入院录反映的是病人入院第一天的诊疗记录，而后 3 者反映的是病人住院全过程。例如，大多数期刊病例讨论文章涉及的就是简要病史。二.基本结构 关于大病史与入院录没有严格的统一规定，但是各医院的要求基本一致。为了教学上的方便，从医学英语写作角度出发，把入院录分成 10 个写作要点（共 20 句）。故称“十点入院录写作法”（Ten-Point Formula）：1.Personal details(details;personal data;patient profile)（个人资料）2.Admission date（入院日期）3.Major complaint（主诉）4.Present history（现病史）5.Simple previous and other histories（过去病史等）6.Physical examination done（体检）7.Laboratory done（实验室检查）8.Impression（印象）9.Problems（问题列单）10.Initial plan for treatment（初步处理）。现病史是入院录的主体，涉及内容较多，包括 5 个小点：.Onset（起病特征）.cause or triggers（促发因素）182第六篇 英语医学写作.evolution（演变）.received treatment（已诊治情况）.general conditions after onset（起病当初一般状况）三.入院录写作方法示例与说明 Admission Note (Example)7.A 25 year-old lady（个人资料）was admitted（被动态）to this hospital on May 11,2003（入院日期）because of fever and cough（主诉）with chill for three days（发病持续间期）.写作要求：?此句体现第-要点：个人资料、入院日期与主诉?1个被动态+4个介词短语；一般过去式?常用句型：The patient entered the hospital；The patient was brought into this hospital；The patient was hospitalized in this hospital。?常用主诉中心词：nausea、vomiting、diarrhea、cough、short of breath、rash、bleeding、pain in some part(epigastrium)、discomfort in some part(anal region)、difficulty in some function(walking)、loss of function(vision)、decrease(increase)of function(libido)、irregular in(menstrual period)。2.Four days ago,the patient took a trip to Guangzhou on business（发病背景）.3.The next day（起病时间）she complained of chill and malaise（起病特征）,and in the afternoon（演变时间）began to cough and temperature went up to 38（演变状况）.4.Self administration of APC and Dicough had no effect（已诊治情况）.5.The patient was in good nutritional and conscious condition on admission（起病当初一般状况）.写作要求：此2句体现第4要点（现病史）?介词或名词短语作时间状语，体现病情演变?3个简单句反映起病特征、演变状况、已诊治经过与发病当初一般情况；用一般过去时。?“起病”常用动词：start，begin，appear,develop，was attacked with?时间状语句式：on the following day,yesterday morning,on September 16,1995?已诊治情况常用句型：be effective to,be ineffective to,be unresponsive to,be un-)responsive to。6.The patient has been healthy and has no special diseases previously including pneumococcal pneumonia and TB and family history.写作要求：?此句反映的是第5要点（过去史）?现在完成时或一般过去时均可?常用时间状语：before，prior to，previous to admission(entry,hospitalization)?家族史常用句型：there is no family history of allergy；there is no family numbers who had TB；the mother is living(fit and well)；father died at 50 of stomach cancer。183第章 入院录与病程录写作 7.Physical examination on admission（小标题）:8.Body temperature(was)38.4;Respiration rate 30/min;.Pulse rate 104 b/min,and BP 108/72mmHg.9.And she was found to be slightly dyspnea.10.The right lower posterior chest showed（也可用主动态）dullness on percussion with moist rales at the end of inspiration on auscultation.写作要求：?此3句反映的是第6要点（体格检查）?生命体征一般用省略句?反映体检结果用被动态；线检查结果用主动态?句子均用一般过去时。?体检常用句型：on examination something was found,there were something abnormal,physical examination revealed that。11.X-ray films of the chest showed cloudy patches over both lower lungs in the posterior-anterior view and the lateral view.12.The white blood cell count was 10.0 x 109/L(8,000/cu mm).13.And the blood has been sampled for liver function,kidney function,arterial gas analysis as well as PCR and bacterial culture.14.Those lab reports havent arrived.写作要求：?此3句反映的是第7要点（实验室检查结果）?实验结果用“主系表”句型?已采样、送样或回报均用现在完成时，常用被动态。?常用动词 revealed,showed,indicated，15.Our impression of the case would be severe acute respiratory syndrome.写作要求：?此句反映的是第8要点（初步印象）?可用虚拟语气：也可陈述语气。?初步印象短语：the initial diagnosis 16.On the day of admission,the patient was given anti-pyretic and ciprofloxacin.17.Oxygen and CPAP have been applied（强调应用至今）.18.However the patients temperature is still going on and dyspnea tends to be more severe.写作要求：?此句反映的是第9要点（问题列单）?入院治疗用被动态，一般过去时或现在完成时?当前问题用一般现在时 19.The patient will be given tracheostomy when necessary.20.And meanwhile the patient will be given prednisolone if the patient develop the early sign of respiratory failure or infiltrate patch is over one third of the both lung fields.写作要求：184第六篇 英语医学写作?此2句反映的是第10要点?诊疗计划用一般将来时条件状语从句。四.入院录示例汉英对照 A 25 year-old lady was admitted to this hospital on May 11,2003 because of fever and cough with chill for three days Four days ago,the patient took a trip to Guangzhou on business.The next day she complained of chill and malaise,and in the afternoon began to cough and temperature went up to 38.Self administration of APC and Dicough had no effect.The patient was in good nutritional and conscious condition on admission.The patient has been healthy and has no special diseases previously including pneumococcal pneumonia and TB.Physical examination on admission:Body temperature(was)38.4;Respiration rate 30/min;.Pulse rate 104 b/min,and BP 108/72mmHg.The patient was in good nutritional and conscious condition.And she was found to be slightly dyspnea.The right lower posterior chest showed dullness on percussion with moist rales at the end of inspiration on auscultation.X-ray films of the chest showed cloudy patches over both lower lungs in the posterior-anterior view and the lateral view.The white blood cell count was10.0 x 109/L(8,000/cu mm).And the blood has been sampled for liver function,kidney function,arterial gas analysis as well as PCR and bacterial culture.Those lab reports havent arrived.Our impression of the case would be severe acute respiratory syndrome.On the day of admission,the patient was given anti-pyretic and ciprofloxacin.Oxygen and CPAP have been applied.However the patients temperature is still going on and dyspnea tends to be more severe.The patient will be given tracheostomy when necessary.And meanwhile the patient will be given prednisolone if the patient develop the early sign of respiratory failure or infiltrate patch is over one third of the both lung fields.Xxx,女，25 岁，因发热、咳嗽伴畏寒 3 天而入院。4 天前，患者去广州出差。次日，患者主诉畏寒与乏力，下午开始咳嗽，体温上升至 38。患者自服APC与敌咳无效。入院十患者营养与意识情况良好。发病前患者健康，无特殊过去病史，包括肺炎球菌性肺炎与肺结核。入院体检：体温 38.4；呼吸 30/分；脉率 104/分；血压 108/72mmHg。发现患者有轻度呼吸困难。扣诊闻及右下胸钝音，听诊闻及呼吸末湿罗音。双侧后前位与侧位X胸片显示双侧下肺叶片状阴影。白血球计数 10.0 x 109/L(8,000/cu mm)。抽血样查肝功能、肾功能、气血分析以及PCR与细菌培养。化验结果尚未回报。此病例印象是急性呼吸综合征。入院当天，病人给予抗热与环丙沙星。已用氧疗与CPAP呼吸机。然而病人体温仍然持续上升，呼吸困难开始加重。必要时对病人行 1 气管切开术。如果病人出现呼吸衰竭早期体征或浸润片状阴影超过两肺 2/3，同时病人将给予强的松治疗。第二节 病程录“SOAP”写作法 病程录（Daily Progress Note）对于双语教学意义不大，故仅作一般介绍。这里的编程录是住院日常诊疗记录，其结构有 4 项：Subjective data、Objective data、Assessment 与 Plan（SOAP）。例如：7-3-8 Anemia（贫血）S：Asymtomatic at bed rest.No more complaint of palpitation.卧床休息时无症状，无心悸。O：Pallor same.Abdomen remains negative.Repeat CBC;RBC 310 x104;Hgb 8.5g/di,Het 25.1%.185第章 入院录与病程录写作 Stools positive for occult blood x2.No bleeding lesions in UGI tract by endoscopy.脸色苍白依旧，腹部检查阴性。复查CBC；红细胞310 x104；血红蛋白8.5g/di；异嗜白细胞 25.1%.A：Hypochromic microcytic anemia with low serum Fe and ferritin certainly indicates iron deficiency anemia.Chronic blood loss from a colonic lesion likely,since UGI bleeding excluded.Although pt denies abnormal menstruations,may need to request.Ob-Gyn consult(R/O uterine myoma).低血色素小红细胞贫血伴低血清铁与铁蛋白，明确提示缺铁性贫血。已排除上胃肠道出血，可能为慢性损害致长期失血。虽然病人否认月经异常，需要妇产科会诊（排除子宫肌瘤）。P：Dx：Schedule for Ba enema.Ob-Gyn consult in AM.Rx.Fergon 1 tab t.i.d.p.c.Ed:The possible cause of her anemia has been explained to her.诊断：计划作钡剂灌肠。下午妇产科会诊。处方：口服 Fergon，1 片 1 次，每日 3 次。教育：向病人解释贫血的可能原因。186