病歷書寫的要領(lǐng)地區(qū)醫(yī)院協(xié)會(huì)研習(xí)會(huì)55-課件

1、地區(qū)醫(yī)院大醫(yī)院執(zhí)行的醫(yī)療作業(yè)較重癥？小醫(yī)院執(zhí)行的醫(yī)療作業(yè)門診、急診為主？大醫(yī)院只會(huì)遇到大??？小醫(yī)院只會(huì)遇到小??？大醫(yī)院的醫(yī)師小醫(yī)院的醫(yī)師大小醫(yī)院都應(yīng)該維持基本的醫(yī)療品質(zhì)新制醫(yī)院評(píng)鑑不分大小醫(yī)院，都要求提供病患同樣好品質(zhì)的醫(yī)療醫(yī)業(yè)的演變醫(yī)療由無(wú)酬的人道工作，成為醫(yī)師可能致富的行業(yè)。醫(yī)學(xué)知識(shí)及醫(yī)療作業(yè)的迅速發(fā)展。對(duì)醫(yī)療品質(zhì)的關(guān)心。社會(huì)的改變。社會(huì)的趨向和醫(yī)療人權(quán)-人人平等、安全第一。民主-處置透明、同意書。法治-有科學(xué)依據(jù)的醫(yī)療 ; 醫(yī)療經(jīng)過(guò)要記載 清楚、要留證據(jù)。監(jiān)察-醫(yī)院評(píng)鑑、專科的評(píng)鑑 （由衛(wèi)生主管單 位或民間）醫(yī)師、醫(yī)院必須按時(shí)依規(guī)矩作業(yè)，並記錄！ 據(jù)實(shí)記載！書寫清楚！優(yōu)良的書寫技巧就是要

2、簡(jiǎn)、明、達(dá)意，用最精簡(jiǎn)的方式、文字，完整地描寫現(xiàn)象、過(guò)程，正確地表達(dá)意見(jiàn)。病歷書寫，要一眼就能看得清清楚楚：因?yàn)椴v內(nèi)容複雜，要注意每天的記錄內(nèi)容要能夠?qū)懗鲆c(diǎn)，不要讓讀者自己東翻西翻找相關(guān)的數(shù)據(jù)。各種病歷書寫的格式、記錄方法與內(nèi)容可能因國(guó)家、地區(qū)、醫(yī)學(xué)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(biāo)總是一樣的。它主要是在清楚地記錄與傳達(dá)正確詳實(shí)的病人訊息以及醫(yī)師評(píng)估與診治的意見(jiàn)，以為病人照護(hù)之依據(jù)，並藉以提昇醫(yī)療照護(hù)品質(zhì)。什麼是完整地描寫？WhoWhat WhenWhereHow-why病歷上的 Who狹義的：誰(shuí)？(很清楚)廣義的：年齡、性別、婚姻、教育、工作、旅遊、接觸、過(guò)去病史、家

3、族史、特殊習(xí)慣、飲食嗜好、等等。病歷上的 When、Where、What、How?What: 發(fā)生什麼事？主訴及其他癥狀？When: 何時(shí)開(kāi)始？癥狀有多久？Where: 在什麼地點(diǎn)開(kāi)始有癥狀？在什麼醫(yī)院或診所看過(guò)？誰(shuí)是醫(yī)師？How-why:為何發(fā)生？ 如何發(fā)生？如何治療過(guò)？用什麼藥物或方法？結(jié)果如何？以後應(yīng)如何？病歷書寫的目的病歷書寫是為的清楚、完整地記載病程、病情，以便醫(yī)師間、護(hù)理人員間、和其他醫(yī)療相關(guān)人員間，互相的溝通（交班、會(huì)診、其他！） 。醫(yī)療品質(zhì)的好壞表現(xiàn)在病歷書寫內(nèi)容(評(píng)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(jì)錄文件 （legal document?。?。以

4、後的調(diào)查及研究。A. 溝通：交班、會(huì)診、其他用處應(yīng)該有Weekly Summary, 以便值班醫(yī)師、或會(huì)診醫(yī)師很快瞭解病情。TPR sheet 應(yīng)該充分利用記載，以便會(huì)診醫(yī)師對(duì)病程可以一目了然。檢驗(yàn)單應(yīng)該用累記式的。病史都要完整、詳細(xì)、精確。體表的變化、 X-ray變化要繪圖或照相。B. 醫(yī)療品質(zhì)：醫(yī)院評(píng)鑑！因?yàn)樵谛轮漆t(yī)院評(píng)鑑中，第列為十四項(xiàng)必須項(xiàng)目之一。必須項(xiàng)目中如有一項(xiàng)不及格，就是醫(yī)院評(píng)鑑醫(yī)療部門不及格?。鹤≡?、門診、急診病歷應(yīng)詳實(shí)記載病況變化及治療方式說(shuō)明等，以供事後檢討。以後的評(píng)鑑有足夠的時(shí)間仔細(xì)看多項(xiàng)紀(jì)錄內(nèi)容！B(續(xù)). 評(píng)鑑：病歷記錄應(yīng)完整詳實(shí)，以POM

5、R方式（clinical path除外）記載（必須項(xiàng)目）病人主訴、病史（含家庭、職業(yè)、等等）及理學(xué)檢查適當(dāng)。一般檢驗(yàn)適當(dāng)，使病人可得到迅速、安全、正確及整體的病情評(píng)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(píng)估病情，視病情及治療情形檢視病況變化、診斷之變化，及對(duì)於治療反應(yīng)之處置。住院記錄：Hx, PE, impression, management plan.各項(xiàng)檢討會(huì)要點(diǎn)之紀(jì)錄。B(再續(xù)). 評(píng)鑑時(shí)還會(huì)注意什麼？（不一定都可以病歷記載）住院病人應(yīng)由適當(dāng)?shù)闹髦吾t(yī)師負(fù)責(zé)照護(hù)，並讓病人知悉其負(fù)責(zé)醫(yī)師 （必須項(xiàng)目）。照會(huì)適切的會(huì)診醫(yī)師、營(yíng)養(yǎng)師等醫(yī)事相關(guān)?？浦魅螒?yīng)

6、對(duì)醫(yī)師之診療狀況加以掌握，並就其問(wèn)題重點(diǎn)加以改善與指導(dǎo) 。主治醫(yī)師、住院醫(yī)師應(yīng)每日迴診並有紀(jì)錄、複簽 。B(再再續(xù)). 評(píng)鑑時(shí)還會(huì)注意什麼？對(duì)病人的申訴或要求能予反應(yīng)、充分說(shuō)明、並記錄之 。同意書、檢查結(jié)果、檢驗(yàn)報(bào)告、手術(shù)紀(jì)錄等必要紀(jì)錄應(yīng)納入病歷 。製作完整且適當(dāng)之住院診療計(jì)畫 ，包括：住院目的、病名、治療以後的經(jīng)過(guò)、檢查計(jì)劃、治療計(jì)劃、護(hù)理計(jì)劃、復(fù)健計(jì)劃、說(shuō)明時(shí)日、說(shuō)明時(shí)會(huì)同的人之姓名等C. 健保審查：如何避免費(fèi)用被剔退說(shuō)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(fèi)用剔退約佔(zhàn)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，

7、說(shuō)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(xiàng)目）解釋數(shù)據(jù)(data)的異常變化，就成為訊息(information) (目前病歷最常見(jiàn)、最大的缺點(diǎn))。C（續(xù)）. 如何避免費(fèi)用被審查剔退說(shuō)明病人為什麼要做此項(xiàng)特殊檢查。醫(yī)師要每天寫，不寫就無(wú)當(dāng)天的診療費(fèi)。詳細(xì)描寫病況或傷勢(shì)、繪圖照相。目前抗生素費(fèi)用剔除原因，大部已是因病歷書寫不夠詳細(xì)，看不出為什麼用藥、用此藥？為什麼改藥？而不是因?yàn)榈谝痪€用上管制性抗生素。這應(yīng)是主治醫(yī)師的責(zé)任。主治醫(yī)師不太瞭解藥物療效，就要設(shè)法學(xué)習(xí)。C (再續(xù)). 如何避免抗生素費(fèi)用被健保剔退？呈現(xiàn)感染確實(shí)存在，必須經(jīng)驗(yàn)性使用抗菌藥。WBC異常增加。（有感染也不一定

8、會(huì)增加）N:L?CRP異常增加。有發(fā)燒。（有感染也不一定會(huì)發(fā)燒）有其他癥狀：例如咳嗽、濃痰、呼吸急促、 等等有徵候： rales, redness, tenderness, swelling, etc其他：CXR、 U/A、CSF、aspirates、培養(yǎng)等的檢驗(yàn)結(jié)果如何？照相、繪畫！每一、兩天詳細(xì)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(jì)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、負(fù)責(zé)。（電腦的病歷記錄應(yīng)如何？Computer-based patient record！）

9、要每天寫：週末、休假也要寫。寫完不能塗改。一定要當(dāng)天馬上寫-隔日寫算是偽造文書。（有糾紛、法院立即扣押病歷?。┫箩t(yī)囑、特殊檢查、給藥的日期及時(shí)間點(diǎn)都要清楚。書寫要清晰可讀?？床欢淖煮w，法院不接受。詳細(xì)描寫病況或傷勢(shì)、繪圖照相。E. 以後的調(diào)查及研究住院期間相關(guān)重要病史不問(wèn)清楚、沒(méi)做該做的檢查，這份病歷將來(lái)無(wú)法用來(lái)調(diào)查或研究。Past medical hx, family hx, social hx,都要完整、詳細(xì)、精確，不清楚就寫不清楚，不能寫沒(méi)有或non-contributory。體表的變化、CXR、其他 X-ray變化要繪圖或照相說(shuō)來(lái)說(shuō)去就是醫(yī)師要自己寫（打）病歷！寫清楚！寫詳細(xì)！醫(yī)師寫

10、病歷是無(wú)可逃避的責(zé)任！（主治）醫(yī)師寫病歷是要持續(xù)到不看病人時(shí)為止！最有效的改善病歷書寫的方法應(yīng)該是先聽(tīng)一次課然後和專家 chart round數(shù)十年的習(xí)慣確是很難一夕之間改變！但還是不得不改！病歷英文要正確、文理通順英文還是中文？要瞭解全世界科學(xué)、醫(yī)學(xué)的新進(jìn)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(dá)清楚，電報(bào)式子句也可。英文不佳，不反對(duì)先用中文補(bǔ)註清楚。以後再學(xué)習(xí)。病歷英文要簡(jiǎn)潔、明瞭“The patient was admitted for evaluation and management.” 可寫成“Admitted through

11、 ER (或 OPD).” 如果是轉(zhuǎn)介來(lái)，就寫為什麼轉(zhuǎn)介。“The patient has been suffering from chronic headache for years.” 可寫成 “Has had chronic headache for 7-8 years”; “Chronic headache, 7-8 years.”“The patient lost body weight”; “ Body weight loss”（可在主訴）. 可寫成 “Bw 69 Kg 3 months ago, 65 Kg now (today)”.病歷書寫常見(jiàn)的問(wèn)題我們應(yīng)注意的病歷書寫重點(diǎn)TP

12、R sheet 要能看出主要的治療、檢查、結(jié)果！Assessment要能看出主治醫(yī)師對(duì)治療過(guò)程、結(jié)果、病人處理的看法！History taking要能看出癥狀、徵候出現(xiàn)的經(jīng)過(guò)，及可能相關(guān)的所有因素！Physical exam要查出所有異常徵候、嚴(yán)重程度！Progress note-POMR ! 內(nèi)容要說(shuō)明為何如此治療、為何用此抗菌藥！Weekly summary、procedure notes、OPD/ER Note-!Discharge Summary要呈現(xiàn)經(jīng)過(guò)整理的住院完整經(jīng)過(guò)！醫(yī)學(xué)用詞縮寫制式的英文錯(cuò)誤。病歷記載內(nèi)容就應(yīng)足夠該能讓會(huì)診者很快的瞭解病情，（不必要求醫(yī)師來(lái)說(shuō)明）！住院記錄夠詳

13、細(xì)嗎？病程記錄？TPR sheet？電子病歷是將來(lái)必走的路。不可事先就打好結(jié)果！切忌張貼同樣字句！無(wú)用的數(shù)據(jù)不必每天打（貼）！英文書寫的要領(lǐng)重點(diǎn)在於簡(jiǎn)、明、達(dá)意多用適當(dāng)?shù)?！出院或入院診斷（和照護(hù)較有關(guān)的）“Stroke” 應(yīng)該寫明是 recent 或 previous，並註明病變、後遺癥的程度：mobility, speech, alertness, etc?！癉ementia” 應(yīng)該寫明是什麼程度的失智；重度（unaware of the surroundings;近乎植物人）、中等度（unable to cooperate;無(wú)法合作）、輕度（disoriented、poor memory、

14、can cooperate）Pulmonary TB: Active? Inactive?住院醫(yī)囑 “Order”的內(nèi)容 誰(shuí)下的、何時(shí)寫的要可以看出來(lái)。DiagnosisAllergyConditionDietActivity and bathroom privileges (BRP) Regular medicationsIV fluids住院醫(yī)囑 “Order”:Allergy Shrimps (urticaria); tomato (pruritus); Penicillin (positive skin test，或 urticaria，或probable anaphylactic r

15、eaction); After an injection at a clinic (fainted，或 skin rashes，或 其他癥狀). Chief Complaint 的寫法：精、簡(jiǎn)，用適當(dāng)?shù)男稳菰~可以更清楚 例一Chest pain today.Chest pain for 2 hours prior to admission (p.t.a.).Precordial pain for 2 hours.Excruciating precordial pain for 2 hours.Sudden onset of excruciating precordial pain 2 hour

16、s ago.Sudden onset of excruciating precordial pain 2 hours ago during exercise. (可放在Present Illness.)Chief Complaint 的寫法：例三Fever, 2 weeks.Low grade fever, 2 weeks.Low grade afternoon fever, 2 weeks.Intermittent (persistent) low grade fever, 2 weeks.Insidious onset of fever, 3 days.Sudden onset of hi

17、gh fever today.Sudden onset of high fever, with shaking chills (=rigor), (或 mild chills, chilly sensation, chillness), today.Sudden onset of high fever, with rigor, today; crampy right flank pain and gross hematuria, 2 days. (可在P.I.)常用的形容詞（可查閱 thesaurus）Severe; moderate; mild, progressively worsenin

18、g.Sudden; acute; insidious; gradual; progressive.Persistent; intermittent; fluctuating; (例如：pain with fluctuating severity).Sharp; vague; crampy; stinging; tingling.Generalized; diffuse; localized; scattered.Decreased; lessened; diminished; subsided; reduced; declined; lowered; got better; improved.

19、Increased; worsened; progressed; degenerated.Present illness 的寫法：不完整電報(bào)式子句High fever up to 39C, sudden onset, daily spike for 4 days; rigor (+) initially; slight dizziness (+) ; poor appetite (+); severe malaise (+)。Visited Dr. Chens clinic (Address:, Tel#:) daily for 3 days, IV injection daily and t

20、wo kinds of t.i.d. tablets; no improvement。查問(wèn)癥狀初發(fā)時(shí)正在做什麼，可以刺激病人的回憶。Muscle ache(+), generalized, severe; mod. bitemporal headache (+).Dry cough, dyspnea, since this morning; rapidly progressive. Came to ER。 Needed oxygen right away。No urinary, or respiratory symptoms. Loose BM x 2; nausea (+)History T

21、aking 尚可加強(qiáng)的部分徹底瞭解病患的生活起居以找出可能病因、危險(xiǎn)因子，預(yù)防疾病再發(fā)、擴(kuò)散Contact with animals, sick people:（住家內(nèi)的人數(shù)）Sexual Hx: (幾乎無(wú)人問(wèn)及!)。過(guò)去、或最近使用的抗生素：可放在Present Illness。對(duì)目前將選用的藥物有直接的影響（療效、過(guò)敏）。必須從過(guò)去的病歷、負(fù)責(zé)的醫(yī)師查問(wèn)為何用藥、用多久、效果如何。（用電話，以爭(zhēng)取時(shí)效）Interpersonal relationship, family life:可瞭解心理狀態(tài)Physical Examination最容易被忽略的是 lymph-nodes 的palpat

22、ion 、heart murmur、rectal、genital、及eye ground exam。要記得請(qǐng)護(hù)士小姐幫忙。不論是用勾選的、或是每項(xiàng)書寫的，都要詳細(xì)描述 positive findings 及 pertinent negative findings.如有 positive findings 要進(jìn)一步做相關(guān)檢查。不能事先就印好結(jié)果：normal, unremarkable等。Management Plan要逐項(xiàng)詳細(xì)記下將要：做哪些檢查、如何用藥、給藥、將會(huì)診什麼科、哪位醫(yī)師。不能只寫 :To give iv fluidsTo give antibioticsTo give pain

23、 killersTo give bronchodilatorsTo give antihypertensivesTo give oral hypoglycemic agents要寫藥名（化學(xué)名）、劑量、給藥途徑及頻率。Progress note 的寫法可以 S.O.A.P. 或 以 problem-oriented medical record (POMR) 方式記載。不論何種方式，其內(nèi)容：一定要記載已接受的治療、主治醫(yī)師對(duì)病情的進(jìn)展及對(duì)醫(yī)療效果的評(píng)估。醫(yī)院評(píng)鑑要求的是POMR目前Assessment 錯(cuò)誤的寫法：就是只重複寫出住院時(shí)之 impression而沒(méi)有評(píng)估Sepsis, R/O p

24、neumoniaType 2 DM, out of controlHistory of cervical CA, S/P total hysterectomy, 8 years.Diarrhea, cause to be determined.Assessment / plan 的寫法(例一)給了什麼治療？有沒(méi)有好轉(zhuǎn)？為什麼？以後如何處理？Sepsis, R/O pneumonia: Third day of cefuroxime 1.5 gm, q8h. Clearly improving. To continue the same Rx. For 6-7 days.Type 2 DM :

25、Glucose level is under control with .Hx/O cervical CA: checked by Gyne. No signs of recurrence. Diarrhea has stopped 3 days after admission. Stool culture (-), cause unknown; related to the pneumonia?(隨期間而會(huì)逐漸改善的治療，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)Assessment / plan 的寫法（例二）給了什麼治療？有沒(méi)有好轉(zhuǎn)？為什麼？以後如何處理？High f

26、ever: 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 check the report of influenza, parainfluenza virus antibodies. Renal function is worsening, will check for Hantavirus and Leptospira antibodies.

27、 No jaundice.Vomited twice yesterday. 2 hours after lunch. No diarrhea. No meningeal signs. Cause not clear. To continue observation.Problem-oriented Progress note 之內(nèi)容按照住院時(shí)列舉之 Impression ，逐項(xiàng)討論。給了什麼治療？有沒(méi)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、肌痛頭痛、等等。再記載有關(guān)此診斷之檢驗(yàn)數(shù)據(jù)，說(shuō)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

28、天。不寫第幾天，就常會(huì)使用過(guò)久。說(shuō)明此問(wèn)題在你的判斷，今天是否比昨天、前天、或住院時(shí)，較好、較壞、或差不多。 分析你認(rèn)為是為什麼？最後說(shuō)明為了解決目前的問(wèn)題，或潛在的問(wèn)題，要再作何檢查或治療。Progress note （Problem-oriented record） 的寫法(例一)Sepsis, R/O pneumonia: Bronchopneumonia confirmed by CXRs on admission. Third day of cefuroxime 1.5 gm, q8h. WBC decreased from 15K 3 days ago to 10K today.

29、Defervesced; less cough. Less rales. No more headache. Clearly improving. To continue the same Rx. For the next 6-7 days.Type 2 DM : Blood glucose down from 215 on admission, to 122 today, under control with Diabenese, po, bid, and with effective control of infection.Hx/O cervical CA: Checked by Gyn

30、e yesterday. No signs of recurrence. Diarrhea has stopped 3 days after admission. Stool culture (-), cause unknown; related to the pneumonia?Progress note （Problem-oriented record） 的寫法（例二）High fever: Still febrile up to 39.3C last evening. WBC still around 10K. Bitemporal headache when febrile. All

31、cultures: no growth. Cause of the fever still unclear. Received 3 days of empiric Unasyn 1.5g, q6h, ceftazidime 2 gm, q8h, and minocyclin 100 mg, bid. Does not seem to be improving. May be viral infection or still be Rickettsial. Will D/C the antibiotic and observe. To check the report of influenza,

32、 parainfluenza virus antibodies. Renal function is worsening, will check for Hantavirus and Leptospira antibodies. No jaundice.Vomited twice yesterday. No diarrhea. No meningeal signs. Cause not clear. To continue observation.TPR 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、其劑量；會(huì)影響TPR的藥物

33、：退燒藥、類固醇、NSAID、抗生素；重要的檢查或處理：手術(shù)、切片檢查、插管拔管、LP、鏡檢、細(xì)菌培養(yǎng)、外送檢驗(yàn)、其他可能常會(huì)問(wèn)到、提到的，和病況進(jìn)展有關(guān)事項(xiàng)；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(hù)人員或其他人員，對(duì)住院後的病程，只看TPR sheet就可以一目瞭然。）醫(yī)學(xué)用詞的縮寫 Abbreviations盡量不用縮寫，以免誤解限制在國(guó)際通用的檢驗(yàn)項(xiàng)目名稱 早期醫(yī)學(xué)院臨床醫(yī)學(xué)初期學(xué)到的基本醫(yī)學(xué)名詞 如有必要使用，應(yīng)在第一次提及時(shí)，先寫出全名，後面以括弧註明將在文內(nèi)使用的簡(jiǎn)寫 所用縮寫也應(yīng)該使用三個(gè)以

34、上的字母，且合乎縮寫的通則 （不合宜的例子：anti, meta, on endo）特別容易誤解的 qd, 及qid，建議都不使用，分別改為 once a day 或 once daily，及four times a day。 綜結(jié)書寫病歷首先要改善的重點(diǎn)病歷記載內(nèi)容就應(yīng)足夠該能讓會(huì)診者很快的瞭解病情，（不必要求醫(yī)師來(lái)說(shuō)明）！TPR sheet住院記錄病程記錄：醫(yī)師的意見(jiàn)電子病歷是將來(lái)必走的路。不可事先就打好結(jié)果！切忌張貼同樣字句！OPD note！無(wú)用的數(shù)據(jù)不必每天貼！Discharge summary不能貼！病歷管理院長(zhǎng)宣導(dǎo)，組織有醫(yī)師成員的病歷管理委員會(huì)，監(jiān)測(cè)品質(zhì)。病歷管理員看已出院病歷

35、之完整性、出院診斷之正確性。病歷管理員看有沒(méi)有做。醫(yī)師評(píng)審看內(nèi)容好壞。各醫(yī)院病歷管理委員會(huì)制訂獎(jiǎng)懲辦法。院長(zhǎng)執(zhí)行。病歷審查表(內(nèi)科系) 總病歷首頁(yè)當(dāng)次住院病歷首頁(yè)(Red sheet）出院病歷:摘要入院記錄 醫(yī)囑單病程記錄 TPR sheet 記載品質(zhì)病程記錄住院醫(yī)師病程記錄是否依SOAP或 POMR方式每日記錄病況（包括新癥候、新數(shù)據(jù)、治療方式、結(jié)果、是否比以前改善、醫(yī)師對(duì)病因及致病機(jī)轉(zhuǎn)的判斷或意見(jiàn)、以後的計(jì)畫）（不能以電腦張貼方式，以致每日內(nèi)容相同）、主治醫(yī)師是否核簽主任或主治醫(yī)師查房記錄是否詳盡由實(shí)習(xí)醫(yī)師記錄是否有住院 醫(yī)師修改及核簽是否詳實(shí)填寫記錄時(shí)間特殊治療記錄是否詳盡每週末及假日前

36、是否寫摘要？病患轉(zhuǎn)科治療時(shí)，是否填妥轉(zhuǎn)科摘要？主治醫(yī)師是否督導(dǎo)填寫及核簽？TPR sheet 是否註明下列項(xiàng)目： 身高體重；主要治療用藥及其劑量；會(huì)影響TPR之藥物投與時(shí)間點(diǎn)；可呈現(xiàn)病情好壞的檢驗(yàn)結(jié)果；特殊檢驗(yàn)時(shí)間點(diǎn)及簡(jiǎn)要結(jié)果，如血液培養(yǎng)、CT、MRI、LP、biopsy、CXR等。 Procedure Note (一定要寫明時(shí)間)Procedure done: spinal tappingIndication: To rule out CNS infection; eye ground showed no signs of increased ICP, and cranial CT show

37、ed no mass.Consent form obtained after thorough explanation to the patient in the presence of RN Chen YJ and the patients motherPatient was laid on his left lateral side in fetal positionLocal anesthesia with 2% Xylocain, 5 mL.22 G spinal tap needle was inserted through the space between L3-L4 witho

38、ut problemCSF, 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 mmHgThere was no complication and the patient tolerated the procedures we

39、ll.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簡(jiǎn)單扼要說(shuō)明這次住院經(jīng)過(guò)問(wèn)題解決的程度目前如何處理中這幾天內(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)題可聯(lián)絡(luò)到我的電話號(hào)碼Weekly SummaryThis 72years old man was admitted on 2004-12-5, because of melena for 2 days prior to admission. Endoscopy reve

40、aled active bleeding ulcer on the duodenum. Packed RBC 8u was given after admission because of 7.8 gm% Hgb. Follow-up Hgb was 11.2 gm%. Tarry stool has stopped now. PPI (Losec 1 amp iv bid) was shifted to oral Nexium 1# qd on 2005-12-10. General condition is stable now. He will be kept under close o

41、bservation, and discharged next Wednesday (Dec.14), if clinically unchanged. He will be followed up at G-I clinic (Dr. C.Y. Lee, Wednesday afternoon) after discharge 下列幾項(xiàng)都需要有內(nèi)容適當(dāng)、可達(dá)到其各自目的的摘要：接班紀(jì)錄（acceptance note） 特珠檢查的申請(qǐng)轉(zhuǎn)診及會(huì)診單的書寫轉(zhuǎn)診或出院說(shuō)明手術(shù)紀(jì)錄及手術(shù)前後紀(jì)錄 則需要依照各科的需要記載Summary note after the Case ConferenceTh

42、is patient was presented to Grand Round of the Department on 2005-12-15. G-I experts all agreed with the diagnosis. Remaining problems exist: (1) Fever: may be from urinary tract infection but biliary tract infection can not be excluded; (2) High CEA and CA 19-9: may be false positive but pancreas s

43、hould be carefully evaluated with abdominal CT. The tests (CA 19-9 and CEA) need to be followed up every 2 months).Only symptomatic treatment is indicated at present.Prof. C. Y. Wang: Addition of pancreatic enzyme may be helpful for evaluation of CA 19-9 data (may convert CA 19-9 to normal).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. Chens 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 pa