医学英语-住院文书格式

医学英语——住院文书格式.txt会计说：“你晚点来领工资吧，我这没零钱。”你看得出我擦了粉吗？虽然你身上喷了古龙水，但我还是能隐约闻到一股人渣味儿。既宅又腐，前途未卜。既宅又腐，前途未卜。你被打胎后是怎么从垃圾桶里逃出来的?史上最神秘的部门：有关部门。不可否认，马赛克是这个世纪阻碍人类裸体艺术进步最大的障碍！1、抗生素医嘱[Antibioticorder]Prophylaxis[预防性用药]Durationofoder[用药时间]24hrProcedure[操作，手术]Empirictheraphy[经验性治疗]Suspectedsiteandorganism[怀疑感染的部位和致病菌]72hrCulturesordered[是否做培养]Documentedinfection[明确感染]Siteandorganism[部位和致病菌]5daysOther[其他]Explanationrequired[解释理由]24hrAntibioticallergies[何种抗生素过敏]Noknownallergy[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/transferto[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]Vitalsigns[测生命体征]I/O[记进出量]Allergies[过敏]3、住院病历[casehistory]Identification[病人一般情况]Name[性名]Sex[性别]Age[年龄]Marriage[婚姻]PersontonotifyandphoneNo.[联系人及电话]Race[民族]I.D.No.[身份证]Admissiondate[入院日期]Sourceofhistory[病史提供者]Reliabilityofhistory[可靠程度]MedicalrecordNo[病历号]BusinessphoneNo.[工作单位电话]HomeaddressandphoneNo.[家庭住地及电话]Chiefcomplaint[主诉]Historyofpresentillness[现病史]PastHistory[过去史]Surgical[外科]病人是否输过血或怀孕过？]*Typeandcrossmatch[血型和血交叉]*Unitsorml[单位或毫升]5、出院小结[dischargesummary]PatientName[病人姓名]MedicalRecordNo.[病历号]AttendingPhysician[主治医生]DateofAdmission[入院日期]DateofDischarge[出院日期]PirncipalDiagnosis[主要诊断]SecondaryDiagnosis[次要诊断]Complications[并发症]Operation[手术名称]ReasonforAdmission[入院理由]PhysicalFindings[阳性体征]Lab/X-rayFindings[化验及放射报告]HospitalCourse[住院诊治经过]Condition[出院状况]Disposition[出院去向]Medications[出院用药]Prognosis[预后]SpecialInstructiontothePatient（diet，physicalactivity）[出院指导（饮食，活动量）]Follow-upCare[随随访]6、住院/出院病历首页[Admission/dischargerecord]Patientname[病人姓名]race[种族]address[地址]religion[宗教]medicalservice[科别]admit（discharge）date[入院（出院）日期]Lengthofstay[住院天数]guarantorname[担保人姓名]nextofkinorpersontonotify[需通知的亲属姓名]relationtopatient[与病人关系]previousadmitdate[上次住院日期]admittingphysician[入院医生]attendingphgsician[主治医生]admittingdiagnosis[入院诊断]final（principal）diagnosis[最终（主要）诊断]secondarydiagnosis[次要诊断]adversereactions（complications）[副作用（合并症）]incisiontype[切口类型]healingcourse[愈合等级]operative（non-operative）procedures[手术（非手术）操作]nosocomialinfection[院内感染]consutants[会诊]Critical-No.oftimes[抢救次数]recovered-No.oftimes[成功次数]Diagnosisqualitativeanalysis[诊断质量]OP.adm.anddischargeDxconcur[门诊入院与出院诊断符合率]ClinicalandpathologicalDxconcur[临床与病理诊断符合率]Pre-andpost-operativeDxconcur[术前术后诊断符合率]Dxdeterminedwithin24hours（3days）afteradmission[入院后24小时（3天）内确诊]Dischargestatus[出院状况]