醫(yī)學病歷書寫注意事項

1、病歷書寫許志宏 醫(yī)師彰化秀傳紀念醫(yī)院2005/10/11病歷的重要性病歷是病人整體的醫(yī)療歷史，是病人病情記載唯一的文字資料，也是醫(yī)師為病人服務(wù)的証據(jù)?？梢宰鳛閷W習、研究及教學之參考，更是法律佐證的重要文件！申請保險給付的重要依據(jù)！病歷書寫的目的病歷書寫為的是清楚、完整地記載病程、病情，以便醫(yī)師間、護理人員間、和其他醫(yī)療相關(guān)人員間，互相的溝通（交班、會診、其他?。?。醫(yī)療品質(zhì)的好壞表現(xiàn)在病歷書寫內(nèi)容(評鑑！)。病歷是醫(yī)療給付的依據(jù)(健保審查！)。病歷是防止醫(yī)療糾紛的紀錄文件 （legal document?。?。以後的調(diào)查及研究。A. 溝通：交班、會診、其他用處應(yīng)該有Weekly Summary或

2、Weekend Summary, 以便值班醫(yī)師、或會診醫(yī)師很快瞭解病情。TPR sheet 應(yīng)該充分利用記載，以便會診醫(yī)師對病程可以一目了然。病史都要完整、詳細、精確。體表外觀的變化、 X-ray變化要繪圖或照相。B. 醫(yī)療品質(zhì)：醫(yī)院評鑑?。鹤≡骸㈤T診、急診病歷應(yīng)詳實記載病況變化及治療方式說明等，以供事後檢討。在新制醫(yī)院評鑑中，第列為十四項必須項目之一。必須項目中如有一項不及格，就是醫(yī)院評鑑醫(yī)療部門不及格！以後的評鑑有足夠的時間仔細看多項紀錄內(nèi)容！B(續(xù)). 評鑑：病歷記錄應(yīng)完整詳實以POMR方式（clinical path除外）記載（必須項目）病人主訴、病史（含家

3、庭、職業(yè)、等等）及理學檢查適當。一般檢驗適當，使病人可得到迅速、安全、正確及整體的病情評估及診斷。病程記錄品質(zhì)，含TPR表上特殊檢查及治療之記錄完整。主治醫(yī)師需親自診療評估病情，視病情及治療情形檢視病況變化、診斷之變化，及對於治療反應(yīng)之處置。住院記錄：Hx, PE, impression, management plan.各項檢討會要點之紀錄。B(再續(xù)). 評鑑時還會注意什麼？（不一定都可以病歷記載）住院病人應(yīng)由適當?shù)闹髦吾t(yī)師負責照護，並讓病人知悉其負責醫(yī)師 （必須項目）。照會適切的會診醫(yī)師、營養(yǎng)師等醫(yī)事相關(guān)。科主任應(yīng)對醫(yī)師之診療狀況加以掌握，並就其問題重點加以改善與指導 。主治醫(yī)師、住院醫(yī)師

4、應(yīng)每日迴診並有紀錄、複簽 。B(再再續(xù)). 評鑑時還會注意什麼？對病人的申訴或要求能予反應(yīng)、充分說明、並記錄之 。同意書、檢查結(jié)果、檢驗報告、手術(shù)紀錄等必要紀錄應(yīng)納入病歷 。製作完整且適當之住院診療計畫 ，包括：住院目的、病名、治療以後的經(jīng)過、檢查計劃、治療計劃、護理計劃、復(fù)健計劃、說明時日、說明時會同的人之姓名等。C. 健保審查：如何避免費用被剔退說明病人為什麼需要繼續(xù)住院（必須描寫病況；“improved” vs “improving”）。藥物費用剔退約佔三分之一以上。其中絕大部分是抗生素！醫(yī)師必須解釋數(shù)據(jù)的變化，說明為什麼用此抗生素、為什麼改藥。（利用健保局規(guī)定的重癥項目）解釋數(shù)據(jù)(da

5、ta)的異常變化 (目前病歷最常見、最大的缺點)。C（續(xù)）. 如何避免費用被審查剔退說明病人為什麼要做此項特殊檢查。醫(yī)師要每天寫病歷，不寫就無當天的診療費。詳細描寫病況或傷勢、繪圖照相。目前抗生素費用剔除原因，大部已是因病歷書寫不夠詳細，看不出為什麼用藥、用此藥？為什麼改藥？而不是因為第一線用上管制性抗生素。不太瞭解藥物療效，就要設(shè)法學習。C (再續(xù)). 如何避免抗生素費用被健保剔退？呈現(xiàn)感染確實存在，必須經(jīng)驗性使用抗菌藥。WBC異常增加。（有感染也不一定會增加）N:L?CRP異常增加。有發(fā)燒。（有感染也不一定會發(fā)燒）有其他癥狀：例如咳嗽、濃痰、呼吸急促、 等等有徵候： rales, redn

6、ess, tenderness, swelling, etc其他：CXR、 U/A、CSF、aspirates、培養(yǎng)等的檢驗結(jié)果如何？照相、繪畫！每一、兩天詳細描寫徵候、癥狀、數(shù)值的升降，改善惡化。用抗生素者，至少每五到七天記載需要繼續(xù)用藥的理由。換用抗生素者，一定要寫換藥的理由。D. 防止醫(yī)療糾紛的紀錄文件 醫(yī)療品質(zhì)的好壞只能從病歷記載看出。主治醫(yī)師應(yīng)該親自簽名以示負責。要每天寫：週末、休假也要寫。寫完不能塗改。一定要當天馬上寫隔日寫算是偽造文書。（有糾紛、法院立即扣押病歷?。鴮懸逦勺x?？床欢淖煮w，法院不接受。詳細描寫病況或傷勢、繪圖照相。下醫(yī)囑、特殊檢查、給藥的日期及時間點都要清楚

7、。E. 以後的調(diào)查及研究住院期間相關(guān)重要病史不問清楚、沒做該做的檢查，這份病歷將來無法用來調(diào)查或研究。Past medical hx, family hx, social hx,都要完整、詳細、精確，不清楚就寫不清楚，不能寫沒有或沒有幫助(non-contributory)。體表的變化、CXR、其他 X-ray變化要繪圖或照相。病歷的書寫各種病歷書寫的格式、記錄方法與內(nèi)容可能因國家、地區(qū)、醫(yī)學院、及醫(yī)院的不同而略有差異，但不論如何，病歷書寫的目標總是一樣的。它主要是在清楚地記錄與傳達正確詳實的病人訊息以及醫(yī)師評估與診治的意見，以為病人照護之依據(jù)，並藉以提昇醫(yī)療照護品質(zhì)。優(yōu)良的書寫技巧就是要簡、

8、明、達意，用最精簡的方式、文字，完整地描寫現(xiàn)象、過程，正確地表達意見。病歷書寫，要一眼就能看得清楚！因為病歷內(nèi)容複雜，要注意每天的記錄內(nèi)容要能夠?qū)懗鲆c，不要讓讀者自己東翻西翻找相關(guān)的數(shù)據(jù)。病歷英文要正確、文理通順英文還是中文？全世界科學、醫(yī)學的新進展差不多都用英文發(fā)表！不論是中文、英文，文理還是要正確通順。英文不一定要用完整的句子，只要意思表達清楚，電報式子句也可。英文不佳，不反對先用中文補註清楚。以後再學習。住院病歷記錄主要內(nèi)容OrdersT.P.R. SheetAdmission NoteProgress NoteConsultation NoteInvasive Procedure R

9、ecordOperation Note麻醉記錄Informed Consent(同意書)給藥記錄護理記錄Discharge SummaryX光及其他醫(yī)學影像報告Admission Orders 住院醫(yī)囑單DiagnosisPerforated peptic ulcer with sepsisUncontrolled DMOld CVA with right hemiplegiaHypertensionAllergyShrimps (urticaria); penicillin (positive skin test或urticaria或probable anaphylactic shock)C

10、onditionCritical or guarded或其他應(yīng)該讓護理人員瞭解的疾病程度DietActivityMedications最好用學名，並註明劑量，儘量不要寫幾顆或幾瓶IV fluids誰下的、何時寫的要可以看出來Discharge Orders醫(yī)囑寫法Discharge this afternoonDischarge tomorrow morningDischarge against medical advice (簡寫為discharge AMA，最好不要寫AAD)不宜寫may be discharge (MBD)！出院指示出院處方必須寫藥的學名、劑量、服用方法、供應(yīng)天數(shù)。後續(xù)安

11、排OPD F/U in 3 days; Referred back to Dr. Lins clinicTPR sheet 可以記載日期、TPR、血壓、身高、體重、I/O、BM，drainage之量；主要的治療藥物、抗生素及其劑量；會影響TPR的藥物：退燒藥、類固醇、NSAID、抗生素、輸血、放射線治療、化療；重要的檢查或處理：手術(shù)、切片檢查、插管拔管、鏡檢、細菌培養(yǎng)、外送檢驗、其他可能常會問到、提到的，和病況進展有關(guān)事項；重要的檢查結(jié)果、需要常常追蹤的數(shù)據(jù)：WBC、CRP、培養(yǎng)結(jié)果、等等；突發(fā)事件：跌倒、昏迷、seizure、等等；（目的就是要使醫(yī)護人員或其他人員，對住院後的病程，只看TPR

12、 sheet就可以一目瞭然。）Admission NoteChief ComplaintsPresent IllnessPast HistoryPersonal, social and occupational historyFamily HistoryReview of SystemsPhysical ExaminationImage and LaboratoryImpressionPlan of management and treatmentAdmission Note Chief Complaints用病人自己的話來描述發(fā)病時間不要只寫出日期、月份或星期Abdominal pain s

13、ince last Sunday. (不好)精簡，適當?shù)男稳菰~Progressive abdominal distention 4 days before (或prior to) admission.Intermittent abdominal pain for 4 hours.Sudden onset of sharp epigastric pain for 2 hours.Tarry stool over the past two days.不能只寫 for operation, for chemotherapy，要加上為什麼要做上述治療！e.g. Colon cancer diagnos

14、ed 2 weeks ago.Admission Note Present Illness記錄原則：按癥狀出現(xiàn)的先後順序記錄時間最好少用日期不要只寫LMD或local hospital慢性病必需記錄使用藥物的名稱和劑量、病人服藥情形和反應(yīng)。Writing “Present Illness”1.開場白-選擇基本資料中之關(guān)鍵詞，融合過去相關(guān)病史及主訴作為開場白，如此可將病例的全貌摘要地呈現(xiàn)出來，有助於列舉出各個問題，並開啟解決問題的步驟。例：This 65 year-old man, who is a construction worker with a history of appendecto

15、my, was admitted from our ER because of intermittent abdominal pain for 2 days. SKH2. 接著，有系統(tǒng)地記載有助於診斷及治療的資料(包括癥狀、過去的檢查、治療與治療的反應(yīng)等)來推敲問題。一些與主訴相關(guān)的negative symptoms或history也應(yīng)寫出，對鑑別診斷相當重要。3. 住院的理由或適應(yīng)癥也應(yīng)在最後簡要地陳述。 SKHWriting “Present Illness”Admission Note Present Illness【例】The 50 y/o male patient is a case

16、 of hypertension, DM and old CVA for 10 years with regular medications.不要稱病人為male or female man or woman, boy or girl.避免稱病人為 “a case” The patient has had hypertension“regular medications” taking medicine as orderedPresent illness 的寫法不完整電報式子句High fever up to 39C, sudden onset, daily spike for 4 days;

17、 rigor (+) initially; slight dizziness (+) ; poor appetite (+); severe malaise (+)。Visited Dr. Chens clinic (Address:, Tel#:) daily for 3 days, IV injection daily and two kinds of t.i.d. tablets; no improvement。查問癥狀初發(fā)時正在做什麼，可以刺激病人的回憶。Muscle ache(+), generalized, severe; mod. bitemporal headache (+).

18、Dry cough, dyspnea, since this morning; rapidly progressive. Came to ER。 Needed oxygen right away。No urinary or respiratory symptoms. Loose stool x 2; nausea (+)Admission Note Past History一般以發(fā)生時間的先後決定記載的次序。手術(shù)史 : 手術(shù)之時間、當時的診斷、有無器官切除、有無輸血、住院多久、追蹤多久。藥物史需特別著重過去對藥品的過敏反應(yīng)，包括多久以前發(fā)生，藥物名稱、發(fā)生時的癥狀及其處理辦法。Admissio

19、n Note Personal, social and occupational history生產(chǎn)史、發(fā)展史、教育程度、職業(yè)現(xiàn)況(職業(yè)與職稱)、婚姻狀況嗜好、習慣、飲食睡眠情況有無抽煙(量及期間)、喝酒(量及種類)、咖啡、檳榔、藥物月經(jīng)、懷孕、生育史Admission Note Family History遺傳或接觸性疾?。哼^敏、癌癥、感染性疾病、精神疾病、糖尿病、高血壓、心臟病、腎臟病、癲癇、痛風、中風等包括至少三代族譜的繪畫History taking 要詳細精確！Admission Note Review of System是為了怕遺漏掉一些訊息，應(yīng)再回顧檢查各器官系統(tǒng)問題、癥狀及疾病

20、。有問題者還要詳細問，並放入Past History或Present Illness中。Admission Note Physical Examination寫出異常的敘述，而不是用診斷的名稱。如：結(jié)膜是蒼白的，可能是貧血，但不要就寫anemic，寫pale就好！鞏膜是黃的，不要寫jaundice，要寫icteric。長度及大小最好使用公分來記，避免用egg-sized, palm-sized等！以圖表示更好，但要精確！Admission Note Impression診斷應(yīng)儘量完整，少用簡寫，除了病名外最好加上程度。Cirrhosis, alcoholic, Child class C; S

21、pleen laceration, Grade I, hemodynamic stable;Old CVA, with right hemiplegia小心用R/O，不要沒有其他診斷就直接寫rule out XXX.Fever, suspected of UTI, R/O drug fever.如果診斷暫時無法確定，可以寫fever或chest pain, cause to be determinedImpression之後宜有Differential Diagnosis.Admission Note Plan依處置之優(yōu)先順序順列，列出預(yù)計檢查與治療的計劃，包括照會、用藥等。不要只寫：To g

22、ive iv fluids.To give antibioticsTo give antihypertensives藥名最好用學名、寫明劑量、給藥途徑及頻率。Progress Note 的寫法一般以Problem-Oriented Medical Record (POMR) 的方式來書寫，最常採用Subjective-Objective-Assessment-Plan (S.O.A.P.) 模式，針對每一個active problem逐項(或擇要)寫出SOAP，特別注意病情的變化、評估及處理方式。應(yīng)每天書寫，內(nèi)容不能一成不變，切忌張貼同樣字句！無用的數(shù)據(jù)不必每天打（貼）！主治醫(yī)師應(yīng)counte

23、r-sign (複簽)，並加以修改或評語與追加。不論何種方式，其內(nèi)容：一定要記載已接受的治療、病情的進展及對醫(yī)療效果的評估。SOAP 記錄方式S (subjective): symptoms (chief complaints)O (objective): signs (physical exam) & lab resultsA (assessment): impression/diagnosis and patient or disease conditionP (plan): approaches to diagnosis (lab tests) approaches to therapy

24、 (medications, procedures, operation, etc.) approaches to healthcare education SKHProblem-oriented Progress note 之內(nèi)容按照住院時列舉之 Impression ，逐項討論。給了什麼治療？有沒有好轉(zhuǎn)（數(shù)據(jù)）？為什麼？以後如何處理？先寫有關(guān)此診斷之癥狀，如肺炎則描寫咳嗽、痰、胸痛、肌肉痛、頭痛、等等。再記載有關(guān)此診斷之檢驗數(shù)據(jù)，說明和前一次是否較高、較低、或差不多。提醒今天是用什麼治療的第幾天。不寫第幾天，就常會使用過久。說明此問題在你的判斷，今天是否比昨天、前天、或住院時，較好、較壞、

25、或差不多。 分析你認為是為什麼？最後說明為了解決目前的問題，或潛在的問題，要再作何檢查或治療。例：#1Chest painS:_O:_A:_P:_#2Upper GI bleedingS.O.A.P.#3ArrhythmiaS.O.A.P. SKHAssessment 錯誤的寫法只重複寫出住院時之impression而沒有評估Sepsis, R/O pneumoniaDM type 2Cervical CA, S/P total hysterectomyDiarrheaAssessment / Plan 的寫法(例一)給了什麼治療？有沒有好轉(zhuǎn)？為什麼？以後如何處理？(隨期間而會逐漸改善的治療，

26、如抗生素、手術(shù)後、及其他大部分處理，應(yīng)該寫今天是第幾天的治療)Sepsis, R/O pneumonia: 3rd day of cefuroxime 1.5 gm. q8h. Clearly improving. To continue the same Rx. for 6-7 days.DM type 2: Sugar level is under control with .History of cervical CA S/P total hysterectomy : Checked by Gyn. No signs of recurrence. Diarrhea has stopped

27、 3 days after admission. Stool culture (-), cause unknown; related to the pneumonia?Assessment / Plan 的寫法(例二 ) 給了什麼治療？有沒有好轉(zhuǎn)？為什麼？以後如何處理？High fever: Received 5 days of empiric clarithromycin 500 mg, bid. Does not seem to be improving. May be viral infection. Will D/C the antibiotic and observe. To che

28、ck the report of influenza, parainfluenza virus antibodies. Renal function is worsening, will check for Hantavirus and Leptospira antibodies. No jaundice.Vomited twice yesterday. 2 hours after lunch. No diarrhea. No meningeal signs. Cause not clear. To continue observation.Weekly SummaryWeekend summ

29、ary幫助值班醫(yī)師瞭解病情。內(nèi)容應(yīng)該含：病人何時住院住院的主要問題是什麼過去一週做了什麼處置病情及治療反應(yīng)如何下週的計畫是什麼不是將住院記錄COPY過來！Consultation Note有照會時除了寫會診單外，應(yīng)該在病程記錄中寫照會那一科的醫(yī)師，並把照會醫(yī)師的回覆意見簡要的寫在病歷裡。寫會診單時應(yīng)多寫有關(guān)病人的病史及檢驗數(shù)據(jù)，下列的客套話可免寫：We sincerely requestYour nationally reputabel expertise,Invasive Procedure Record所有侵入性的檢查和處置都應(yīng)以紅筆記錄，包括：各種內(nèi)視鏡檢查、血管攝影、組織切片、各種體液

30、抽取、導管放置、氣管插管等記錄內(nèi)容：執(zhí)行時間、地點執(zhí)行的原因、方法、麻醉方式檢查時的發(fā)現(xiàn)、處置方法、有無併發(fā)癥執(zhí)行者及協(xié)助者姓名Discharge Summary 應(yīng)注意事項 (1)1. 出院診斷Primary (主要診斷) 引起病人此次住院的主要病況Secondary (次要診斷) 原已存在或者後來才發(fā)展的病況，且影響醫(yī)療/住院天數(shù)者。* 與此次住院醫(yī)療無關(guān)的疾病不應(yīng)包括在內(nèi)例: 主要診斷：1) acute congestive heart failure2) acute myocarditis 次要診斷：1) aspiration pneumonia2) ventricular tachy

31、cardia SKHDischarge Summary 應(yīng)注意事項 (2)2. Brief history：不要重覆冗長的住院記錄中所寫的present illness，應(yīng)簡單地描述病人住院之理由及相關(guān)的現(xiàn)在病史。3. Hospital course：應(yīng)扼要地依時程描述(不要用列表方式)病人住院期間所作過的主要檢查與治療經(jīng)過。4. 檢驗結(jié)果 (Lab results)：不應(yīng)列出所有的血液及生化報告，應(yīng)將他們消化後，寫出與病況有關(guān)的positive與pertinent negative findings。 SKHDischarge Summary 應(yīng)注意事項 (3)5. Discharge me

32、dications：應(yīng)以獨立heading列出所有出院用藥，藥物名稱須用generic name；要寫出劑量(100 mg，不寫one tablet)與用法。6. Follow-up plan (追蹤計劃)。7. Instructions to the patient (給病人的指示)：這點在國內(nèi)做得最不夠，常被忽略。衛(wèi)生署的病歷書寫範例也沒特別強調(diào)，只是列舉“出院後之建議及用藥” (Recommendations and medications)。8. 應(yīng)寫出referring physician或primary care physician 的名字，並且寄一份出院摘要的影印本給他們。 SK

33、H以英文記載病歷常見的錯誤性別、所有格的錯誤【例】：Patient is a 62 years old female, his chief complaint is abdominal pain.建議：The Patient is a 62 years old woman, her chief complaint is abdominal pain.有關(guān)主訴（chief complaint）的寫法：1.The patient is a 62-year-old woman, and her chief complaint is abdominal pain.2.A 12-year-old gir

34、l complained of abdominal pain.3.A 7-year-old boy was admitted to the hospital because of abdominal pain.A 40-year-old man presented with abdominal pain.* Do not just use male or female; write “man” or “woman”.時態(tài) (tense) 的錯誤【例】：He had hypertension and still on three kinds of antihypertensive.建議：He h

35、as hypertension and still on three kinds of antihypertensives.He has hypertension and is on three kinds of antihypertensives.He has hypertension and is on three kinds of antihypertensive medications.【例】：Before he came to our clinic today, he had ever went to another two hospital clinics.建議：Before he

36、 came to our clinic today, the patient had visited clinics at two other hospitals.建議：Before he came to our clinic today, the patient had been to clinics at two other hospitals.介系詞的錯誤【例】：In last Saturday, his headache was suddenly got worse. 建議：Last Saturday, his headache suddenly got worse.【例】：The p

37、atient had an acute process superimposed to his background conditions. 建議：The patient had an acute process superimposed on his background conditions.【例】: A 45 year-old woman of mitral stenosis. 建議 : A 45 year-old woman with mitral stenosis.主詞的錯誤【例】：Cancer was told這是主詞弄亂了。建議：The patient was informed

38、to have cancer.The patient was told to be having cancer.He was diagnosed to have cancer. He was told to have cancer.單字、單詞的錯誤【例】：Acception note 建議：沒有acception一字，應(yīng)該是 acceptance note 或 on service note (相對的可寫off service note)【例】：Progression note；Progressive note. 建議：應(yīng)寫成 Progress note?！纠?: Past history:

39、 Nil. 建議 : Nil is a Latin word; it means “nothing” or “Zero”. 應(yīng)寫成 “Non-contributory”.單字、單詞的錯誤(續(xù))【例】：Discharge diagnosis: R/O cancer.建議: R/O (rule out) 是“須排除”、“應(yīng)排除”之意，R/O cancer 可用於住院時的診斷。不過住院診斷工作 (work up) 之後，癌癥的診斷應(yīng)該是已經(jīng)被ruled in 或ruled out。如診斷仍未被確認，而癌癥還是最有可能，則應(yīng)寫成Discharge diagnosis: probable cancer或

40、suspected cancer?！纠浚簊epsis、septicemia、bacteremia的用法。建議：有感染癥狀時稱為sepsis (敗毒癥)，再加上血液培養(yǎng)有細菌，則稱為septicemia (敗血癥) 。只血液培養(yǎng)有細菌則稱為bacteremia (菌血癥)。醫(yī)用英文翻譯成中文時，應(yīng)該注意其原有的希臘文或拉丁文的字根意義。錯誤使用 positive 或 negative【例】：The biopsy was negative. The exercise testwas positive. The ECG was negative. 檢驗結(jié)果不要用“positive”或“negati

41、ve”這些應(yīng)該寫為：Laboratory tests (studies) gave normal results. Laboratory tests showed normal values.Laboratory data were normal (or within normal limits).The result of the biopsy was unremarkable.The exercise test was abnormal. The ECG revealed no abnormality.Nothing particular (N.P)或non-made的誤用在病歷書寫時應(yīng)避

42、免寫“無特殊之處”，應(yīng)該寫出詢問出什麼，結(jié)果正常、或無發(fā)現(xiàn)；或是做了檢查，結(jié)果正常。故英文應(yīng)用negative for, unremarkable, non-contributory等字詞?！纠浚篢he family history was nothing particular.應(yīng)改為：The family history was unremarkable (or non-contributory).Non-made是說做了切片檢查，沒有發(fā)現(xiàn)不正常的（癌）細胞。但是，英文不這麼說?！纠浚篢he biopsy was non-made. The pathology was non-made.

43、 應(yīng)改為：The pathology did not reveal malignant cells.或是No malignant cells were found in the biopsy specimen.贅語或俗語常使用兩個名詞連在一起，或是為節(jié)省書寫將一些簡寫當作名詞或動詞。肝硬化應(yīng)該是cirrhosis，而常寫成liver cirrhosis或是cirrhosis of the liver. Cirrhosis本身就是肝硬化，因此不須加上liver。seizure attack, 只需寫seizure，或epileptic fit。a tumor mass，應(yīng)寫為 a tumor,

44、a mass (lesion)。fever of 38C應(yīng)寫為 (fever with) a temperature of 38C。The patient was AAD (against advice discharge, 自動出院)，應(yīng)寫為The patient was discharged AMA (against medical advice) 或 to be discharged AMA 或 discharge AMA。The patient MBD (may be discharged ) today. 意思是“可以出院”，應(yīng)寫為The patient is ready for d

45、ischarge today.或to be discharged；discharge today；discharge tomorrow morning 或 discharge in AM 。其他常見的不當使用語詞VictimVictim翻譯是“受害者”，病人雖然受病痛，但是使用這個字不當。何況已經(jīng)寫patient，不須再用victim?！纠浚篢he patient is a victim of type 1 DM diagnosed since 2 years ago.應(yīng)寫為：The patient was diagnosed as having type 1 DM two years ag

46、o.【例】 : The patient is a victim of motor vehicle accident (MVA).應(yīng)寫為 : The patient had a MVA.其他常見的不當使用語詞Unfortunately常見病歷寫Unfortunately, the patient had.，這個意思是說病人的情況本來是穩(wěn)定的，但是後來發(fā)生了某些癥狀或是事件。病人生病本來就是不幸的事，不須再強調(diào)，不須以哀傷的語氣如unfortunately、sadly、miserably、unluckily等呈現(xiàn)在病歷。【例】：Unfortunately, nausea, vomiting and

47、 abdominal pain developed since last night, and the patient was brought to ER for help. 應(yīng)改為：The patient was well until last night when nausea, vomiting and abdominal pain developed, and he was brought to the ER. 其他常見的不當使用語詞A test (or examination) was arranged (performed), which showed不須寫安排或者執(zhí)行什麼檢查，直

48、接寫出檢查發(fā)現(xiàn)什麼即可。【例】：CT scan of the head was arranged (performed), which showed subdural hematoma over the left parietal area. 應(yīng)改為：A CT scan of the head showed subdural hematoma over the left parietal area.其他常見的不當使用語詞Culture showed bacteria細菌培養(yǎng)長出細菌不適用show或reveal，應(yīng)該用yield 或 grow【例】：The sputum culture show

49、ed Streptococcus pneumoniae infection. 應(yīng)改為：The sputum culture yielded (grew) Sreptococcus pneumoniae.Bacterial culture was positive for Streptococcus pneumoniae.其他常見的不當使用語詞According to the statement of the patient這似乎強調(diào)這份病歷是病人親口說的，其實病歷不是司法的筆錄，只要說是根據(jù)病人或誰陳述即可，或是直接說病人如何。應(yīng)改為：According to the patient, . 或

50、 The patient stated that she had epigastric discomfort 30 minutes after last dinner.According to the patients mother, 其他常見的不當使用語詞During the period of admission這是中式英語的另一例子，亦即“住院期間”。但是admission是由醫(yī)院進入病房的一個行為，因此沒有所謂period。應(yīng)該寫為During the hospitalization或是During the hospital stay。其他常見的不當使用語詞A disease was

51、diagnosed.The patient was diagnosed as a disease.中文的意思是很簡單，“病人診斷什麼病”，但是英文不能寫為“疾病被診斷”；也不能寫為 “病人被診斷成（as a disease）什麼病”?！纠浚篊olon cancer was diagnosed.應(yīng)改為：The patient was diagnosed as having colon cancer. 或是 A diagnosis of colon cancer was made.其他常見的不當使用語詞使用太多連接詞，使句子太長 The patient went to the hospital

52、and was diagnosed of osteoarthritis, so medications were given and the pain decreased in severity, but she had to take the medicines regularly. 應(yīng)改為：The patient went to the hospital, where a diagnosis of osteoarthritis was made. She took analgesics regularly with some relief of her pain.其他常見的不當使用語詞Ir

53、regular control, Regular medication?？吹讲v寫irregular control或irregular medication或regular medication。例如，The patient has hypertension for 10 years with irregular medications. 這也是中式英語，意思是說病人規(guī)則(按時)或不規(guī)則(不按時)服藥。先說regular medication並不能說病人一定是按時服藥，服一天藥休息一天，也是“規(guī)則“的。因此相對的“不規(guī)則“也顯得沒意義。不按時服藥可能是病人疏忽、不在意自己的病情、或是服藥發(fā)生

54、不良反應(yīng)。這些應(yīng)該區(qū)分清楚，才能進一步對病人處置。應(yīng)該修改為：The patient has had hypertension for 10 years, but he did not take medicine as ordered. The patient has had hypertensive for 10 years, but he has not been taking medicine regularly.其他常見的不當使用語詞EverEver一字英漢字典翻譯成曾經(jīng)，但其實是at anytime past or future, 有always constantly之意，不能依中文

55、曾經(jīng)的用法在英文句子中出現(xiàn)！【例】：The patient ever went to a hospital.建議：The patient has been to a hospital.The patient did go to a hospital.The patient went to a hospital.其他常見的不當使用語詞【例】：The patient is anemia. Conscious: clear. 建議：The patient is anemic. 或 The patient has anemia. Consciousness: clear. 或 Consciousnes

56、s: alert, 【例】：Mentality clear建議：mentality是智力、悟性，通常病患並不做智力測驗，應(yīng)該寫Consciousness (知覺、意識) clear。形容詞名詞其他常見的不當使用語詞In vain【例】The patient went to an LMD for treatment but in vain.建議：The patient went to an LMD for treatment, but the symptoms did not improve. (或 the treatment was not effective)病人不是“去”醫(yī)師診所這件是徒然

57、無功(迷路了)，in vain此字非專業(yè)用語。其他常見的不當使用語詞【例】：The patient developed abdominal pain and high fever.建議：Abdominal pain and high fever developed.因癥狀不是病人使它發(fā)生?！纠浚篢hank you for the consultation.建議：Thank you for the referral. Thank you for the consultation request. 或簡單地 Thanks! 但不能寫Thank you for the consultation（這

58、樣寫變成感謝自己的意見了）?！纠浚篋ear Dr.；We sincerely request建議：會診單本來就是要求醫(yī)師來評估、建議，本來就是看得起被要求會診的醫(yī)師而發(fā)。因此 Dear Dr. ; We sincerely request; your expertise; 等等敬頌詞句被省略也應(yīng)該不失禮。英文病歷常用語句病人或家人描述陳述Tell, state, claim, assert, describe, said認為Think, feel, believe, suspect根據(jù)、聲稱According to根據(jù)所憶To the best of ones memory, as ones

59、 recall就其所知To ones knowledge, as far as one knowsExamplesThe patient stated (claimed, said) that he had abdominal pain just after meals.The patient suspected (thought) that he acquired his infection during a journey to the Mainland China one week ago.According to the patients son, he was noted disor

60、iented in time about 2 weeks ago.發(fā)現(xiàn)癥狀或發(fā)病、檢查發(fā)現(xiàn)癥狀開始Start, begin, appear, occur, develop表現(xiàn)出Manifest, exhibit注意、發(fā)現(xiàn)Note, notice, find, aware of, feel, complain of遭受、遭遇Suffer, experience(檢查)發(fā)現(xiàn)Reveal, show, detect, discloseExamplesThe patient began to have diarrhea 3 days ago. (Diarrhea started 3 days ago.