1、抗生素醫(yī)囑[Antibiotic order]
•Prophylaxis [預(yù)防性用藥] Duration of oder[用藥時(shí)間] 24hr
Procedure[操作，手術(shù)]
•Empiric theraphy [經(jīng)驗(yàn)性治療]
Suspected site and organism[懷疑感染的部位和致病菌] 72hr
Cultures ordered[是否做培養(yǎng)]
•Documented infection[明確感染]
Site and organism[部位和致病菌] 5days
•Other[其他]
Explanation required [解釋理由] 24hr
•Antibiotic allergies[何種抗生素過敏]
No known allergy [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 / transfer to [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]
•Vital signs[測生命體征]
•I / O [記進(jìn)出量]
•Allergies[過敏]
3、住院病歷[case history]
•Identification [病人一般情況]
Name[性名]
Sex[性別]
Age [年齡]
Marriage[婚姻]
Person to notify and phone No.[聯(lián)系人及電話]
Race[民族]
I.D.No.[身份證]
Admission date[入院日期]
Source of history[病史提供者]
Reliability of history[可靠程度]
Medical record No[病歷號]
Business phone No.[工作單位電話]
Home address and phone No.[家庭住地及電話]
•Chief complaint[主訴]
•History of present illness[現(xiàn)病史]
•Past History[過去史]
Surgical[外科]
Medical[內(nèi)科]
Medications[用藥]
Allergies[過敏史]
Social History[社會史]
Habits[個人習(xí)慣]
Smoking[吸煙]
Family History[家族史]
Ob/Gyn History[ 婚姻/生育史]
Alcohol use[喝酒]
•Review of Aystems[系統(tǒng)回顧]
General[概況] 醫(yī)學(xué)全在線www.med126.com
Eyes,Ears,Nose and throat[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)]
•Physical Exam[體檢]
Vital Signs[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]
Heart rate[心率]
Heart rhythm[心律]
Heart Border[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)]
cranial nerves[顱神經(jīng)]
sensation[感覺]
Motor[運(yùn)動]
*Special P.E. on diseased organ system[專科情況]
*Radiographic Findings[放射]
*Laboratory Findings[化驗(yàn)]
*Assessment[初步診斷與診斷依據(jù)]
*Summary[病史小結(jié)]
*Treatment Plan[治療計(jì)劃]
