住院文書格式

住院文書格式.txt假如有一天你想哭打電話給我不能保證逗你笑但我能陪著你一起哭。堅強的基本，就是微笑。面具戴久了、就成了皮膚e住院文書格式1、抗生素醫(yī)囑［Antibioticorder］Prophylaxis［預(yù)防性用藥］Durationofoder［用藥時間］24hrProcedure［操作，手術(shù)］Empirictheraphy［經(jīng)驗性治療］Suspectedsiteandorganism［懷疑感染的部位和致病菌］72hrCulturesordered［是否做培養(yǎng)］Documentedinfection［明確感染］Siteandorganism［部位和致病菌］5days?Other［其他］Explanationrequired［解釋理由］Antibioticallergies［何種抗生素過敏］Noknownallergy［無已知的過敏］Drug+dose+Route+frequency［藥名+劑量+途徑+次數(shù)］2、醫(yī)囑首頁［Admission/transfer］Admit/transferto［收入或轉(zhuǎn)入］Resident［住院醫(yī)師］Attending［主治醫(yī)師］Condition［病情］Diagnosis［診斷］?Diet［飲食］Acitivity［活動］Vitalsigns［測生命體征］I/O［記進出量］Allergies［過敏］3、住院病歷［casehistory］Identification［病人一般情況］Name［性名］Sex［性別］Age［年齡］Marriage［婚姻］PersontonotifyandphoneNo.［聯(lián)系人及電話］Race［民族］I.D.No.［身份證］Admissiondate［入院日期］Sourceofhistory［病史提供者］Reliabilityofhistory［可靠程度］MedicalrecordNo［病歷號］BusinessphoneNo.［工作單位電話］HomeaddressandphoneNo.［家庭住地及電話］,Chiefcomplaint］主訴］,Historyofpresentillness］現(xiàn)病史］PastHistory］過去史］Surgical］外科］Medical］內(nèi)科］Medications］用藥］Allergies］過敏史］SocialHistory］社會史］Habits］個人習(xí)慣］Smoking］吸煙］FamilyHistory］家族史］Ob/GynHistory］婚姻/生育史］Alcoholuse］喝酒］ReviewofAystems］系統(tǒng)回顧］General］概況］Eyes,Ears,Noseandthroat］五官］Pulmonary］呼吸］Cardiovascular］心血管］GI］消化］GU］生殖、泌尿系統(tǒng)］Musculoskeletal］肌肉骨骼］Neurology］神經(jīng)系統(tǒng)］Endocrinology］內(nèi)分泌系統(tǒng)］Lymphatic/Hematologic］淋巴系統(tǒng)/血液系統(tǒng)］PhysicalExam］體檢］VitalSigns］生命體征］P］脈博］Bp］血壓］R］呼吸］T］溫度］Height］身高］Weight］體重］General］概況］HEENT］五官］Neck］頸部］Back/Chest］背部/胸部］Breast］乳房］Heart］心臟］Heartrate］心率］Heartrhythm］心律］HeartBorder］心界］Murmur］雜音］Abdomen］腹部］Liver］肝］Spleen］脾］Rectal］直腸］Genitalia［生殖系統(tǒng)］Extremities］四肢］Neurology［神經(jīng)系統(tǒng)］cranialnerves［顱神經(jīng)］sensation］感覺］Motor］運動］*SpecialP.E.ondiseasedorgansystem［?？魄闆r］*RadiographicFindings］放射］*LaboratoryFindings］化驗］*Assessment［初步診斷與診斷依據(jù)］*Summary］病史小結(jié)］*TreatmentPlan］治療計劃］4、輸血申請單］Bloodbankrequisitionform］(1)reasonforinfusion］輸血原因］▲紅細胞］packedredcells,wshedRBCs］:*Hb<8.5［血色素<8.5］*>20%bloodvolumelost］>20%血容量丟失］*cardio-pulmonarybypasswithanticipatedHb<8］心肺分流術(shù)伴預(yù)計血色素<8］*chemotherapyorsurgerywithHb<10］血色素<10的化療或手術(shù)者］▲全血］wholeblood］:massiveon-goingbloodloss］大量出血］▲血小板〔platelets］:*massivebloodtransfusion>10units］輸血10單位以上者］*plateletcount<50X103/plwithactivebleedingorsurgery血小板<5萬伴活動性出血或手術(shù)者］*Cardio-pulmonarybypassuithpl<100X103/plwithoctivebleeding］心肺分流術(shù)伴血小板<10萬，活動性出血者］*Plateletcount<20X103/pl］血板<2萬］▲新鮮冰凍血漿］freshfrozenplasma］:*documentedabnormalPTorPTTwithbleedingorSurgery］PTPTT異常的出血或手術(shù)病人］*specificclottingfactordeficiencieswithbleeding/surgerg］特殊凝血因子缺乏的出血/手術(shù)者］*bloodtransfusion>15units］輸血>15個單位］*warfarinorantifibrinolytictherapywithbleeding］華法令或溶栓治療后出血］*DIC］血管內(nèi)彌漫性凝血］*AntithrombinIIIdficiency］凝血酶III缺乏］(2)輸血要求］requestforbloodcomponents］*patientbloodgroup］血型］*Hasthepatienthadtransfusionorpregnancyinthepast3months?［近3個月，病人是否輸過血或懷孕過？］*Typeandcrossmatch］血型和血交叉］*Unitsorml］單位或毫升］5、出院小結(jié)［dischargesummary］PatientName［病人姓名］MedicalRecordNo.［病歷號］AttendingPhysician［主治醫(yī)生］DateofAdmission［入院日期］DateofDischarge［出院日期］PirncipalDiagnosis［主要診斷］SecondaryDiagnosis［次要診斷］Complications］并發(fā)癥］Operation］手術(shù)名稱］ReasonforAdmission］入院理由］PhysicalFindings］陽性體征］Lab/X-rayFindings］化驗及放射報告］HospitalCourse］住院診治經(jīng)過］Condition］出院狀況］Disposition］出院去向］Medications］出院用藥］Prognosis］預(yù)后］SpecialInstructiontothePatient(diet,physicalactivity)］出院指導(dǎo)(飲食，活動量)］Follow-upCare］隨訪］6、住院/出院病歷首頁］Admission/dischargerecord］Patientname］病人姓名］race］種族］address］地址］religion］宗教］medicalservice］科別］admit(discharge)date］入院(出院)日期］Lengthofstay［住院天數(shù)］guarantorname［擔(dān)保人姓名］nextofkinorpersontonotify］需通知的親屬姓名］relationtopatient］與病人關(guān)系］previousadmitdate］上次住院日期］?admittingphysician］入院醫(yī)生］attendingphgsician］主治醫(yī)生］admittingdiagnosis］入院診斷］final(principal)diagnosis］最終(主要)診斷］secondarydiagnosis］次要診斷］adversereactions(complications)］副作用(合并癥)］incisiontype［切口類型］healingcourse［愈合等級］operative(non-operative)procedures［手術(shù)(非手術(shù))操作］nosocomialinfection［院內(nèi)感染］consutants［會診］Critical-No.oftimes［搶救次數(shù)］recovered-No.oftimes［成功次數(shù)］Diagnosisqualitativeanalysis［診斷質(zhì)量］OP.adm.anddischargeDxconcur［門診入院與出院診斷符合率］ClinicalandpathologicalDxconcur［臨床與病理診斷符合率］Pre-andpost-operativeDxconcur［術(shù)前術(shù)后診斷