留学生查房日常用语1、抗生素医嘱[Antibioticorder]Prophylaxis预防性用药Durationofoder用药时间Procedure操作，手术Empirictheraphy经验性治疗Suspectedsiteandorganism怀疑感染的部位和致病菌Culturesordered做培养Documentedinfection明确感染Siteand organism部位和致病菌Explanationrequired解释理由Antibioticallergies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生命体征I/O记进出量Allergies过敏3、住院病历[casehistory]
留学生查房日常用语 1、抗生素医嘱[Antibiotic order] Prophylaxis 预防性用药 Duration of oder 用药时间 Procedure 操作，手术 Empiric theraphy 经验性治疗 Suspected site and organism 怀疑感染的部位和致病菌 Cultures ordered 做培养 Documented infection 明确感染 Site and organism 部位和致病菌 Explanation required 解释理由 Antibiotic allergies 何种抗生素过敏 No known allergy 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 / transfer to 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 Vital signs 生命体征 I / O 记进出量 Allergies 过敏 3、住院病历[case history]
Identification病人一般情况Name姓名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Chief complaint主诉Historyofpresentillness现病史PastHistory过去史Surgical外科Medical 内科Medications用药Allergies过敏史Social History社会史Habits个人习惯Smoking吸烟FamilyHistory家族史Ob/GynHistory婚姻/生育史Alcohol use喝酒ReviewofSystems系统回顾General概况Eyes,Ears,Noseandthroat五官
Identification 病人一般情况 Name 姓名 Sex 性别 Age 年龄 Marriage 婚姻 Person to notify and phone No. 联系人及电话 Race 民族 I.D.No. 身份证 Admission date 入院日期 Source of history 病史提供者 Reliability of history 可靠程度 Medical record No 病历号 Business phone No 工作单位电话 Home address and phone No 家庭住地及电话 Chief complaint 主诉 History of present illness 现病史 Past History 过去史 Surgical 外科 Medical 内科 Medications 用药 Allergies 过敏史 Social History 社会史 Habits 个人习惯 Smoking 吸烟 Family History 家族史 Ob/Gyn History 婚姻/生育史 Alcohol use 喝酒 Review of Systems 系统回顾 General 概况 Eyes,Ears,Nose and throat 五官
Pulmonary呼吸Cardiovascular心血管GI消化GU生殖、泌尿系统Musculoskeletal肌肉骨骼Neurology神经系统Endocrinology内分泌系统Lymphatic/Hematologic淋巴系统/血液系统PhysicalExam体检Vital Signs生命体征P脉博Bp血压R呼吸T温度Height身高Weight体重General概况HEENT五官Neck颈部Back/Chest背部/胸部Breast乳房Heart心脏Heartrate心率Heart rhythm心律HeartBorder心界Murmur杂音Abdomen腹部Liver 肝Spleen 脾Rectal直肠
Pulmonary 呼吸 Cardiovascular 心血管 GI 消化 GU 生殖、泌尿系统 Musculoskeletal 肌肉骨骼 Neurology 神经系统 Endocrinology 内分泌系统 Lymphatic/Hematologic 淋巴系统/血液系统 Physical Exam 体检 Vital Signs 生命体征 P 脉博 Bp 血压 R 呼吸 T 温度 Height 身高 Weight 体重 General 概况 HEENT 五官 Neck 颈部 Back/Chest 背部/胸部 Breast 乳房 Heart 心脏 Heart rate 心率 Heart rhythm 心律 Heart Border 心界 Murmur 杂音 Abdomen 腹部 Liver 肝 Spleen 脾 Rectal 直肠
Genitalia生殖系统Extremities四肢Neurology神经系统cranial nerves颅神经sensation感觉Motor运动*SpecialP.E.ondiseasedorgansystem[专科情况]*RadiographicFindings[放射]*LaboratoryFindings[化验]*Assessment[初步诊断与诊断依据]*Summary[病史小结]*Treatment Plan[治疗计划]4、输血申请单[Blood bank requisitionform](1)reasonforinfusion[输血原因]红细胞[packedredcells,washedRBCs]*Hb20%bloodvolumelost[>20%血容量丢失]*cardio-pulmonarybypasswithanticipatedHb10units[输血10单位以上者]*plateletcount<50x103/μlwithactivebleedingorsurgery[血小板<5万伴活动性出血或手术者]*Cardio-pulmonarybypassuithp<100x103/μlwithoctivebleeding[心肺分流术伴血小板<10万，活动性出血者]*Plateletcount<20×103/μl[血板<2万]新鲜冰冻血浆[freshfrozenplasma]*documentedabnormal PTorPTTwithbleedingorSurgery[PT、PTT异常的出血或手术病人]
Genitalia 生殖系统 Extremities 四肢 Neurology 神经系统 cranial nerves 颅神经 sensation 感觉 Motor 运动 *Special P.E. on diseased organ system[专科情况] *Radiographic Findings[放射] *Laboratory Findings[化验] *Assessment[初步诊断与诊断依据] *Summary[病史小结] *Treatment Plan[治疗计划] 4、输血申请单[Blood bank requisition form] (1)reason for infusion[输血原因] ▲红细胞[packed red cells, washed RBCs]: *Hb20% blood volume lost [>20%血容量丢失] *cardio-pulmonary bypass with anticipated Hb 10 units[输血10单位以上者] *platelet count <50×103/μl with active bleeding or surgery[血小板<5万伴活动性出血或手术者] *Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流术伴血小板<10万， 活动性出血者] *Platelet count <20×103/μl[血板<2万] ▲新鲜冰冻血浆[fresh frozen plasma]: *documented abnormal PT or PTT with bleeding or Surgery[PT、PTT异常的出血或手术病人]
*specificclottingfactordeficiencieswithbleeding/surgerg[特殊凝血因子缺乏的出血/手术者]*bloodtransfusion>15units[输血>15个单位]*warfarinorantifibrinolytictherapywithbleeding[华法令或溶栓治疗后出血]*DIC[血管内弥漫性凝血]*AntithrombinIIdficiency[凝i酶III缺乏](2)输血要求[requestforbloodcomponents]*patientbloodgroup[血型]*Hasthepatient hadtransfusionorpregnancyinthepast3months?[近3个月，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[discharge summary]Patient Name[病人姓名]MedicalRecordNo.[病历号]AttendingPhysician[主治医生]Date of Admission[入院日期]Dateof Discharge[出院日期]Pirncipal Diagnosis[主要诊断]Secondary Diagnosis[次要诊断]Complications[并发症]Operation[手术名称]ReasonforAdmission[入院理由]Physical Findings[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）]
*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手术者] *blood transfusion >15units[输血>15个单位] *warfarin or antifibrinolytic therapy with bleeding[华法令或溶栓治疗后出血] *DIC[血管内弥漫性凝血] *Antithrombin III dficiency[凝血酶III 缺乏] (2)输血要求[request for blood components] *patient blood group[血型] *Has the patient had transfusion or pregnancy in the past 3 months? [近3个月，病人是否输过血或 怀孕过？] *Type and crossmatch[血型和血交叉] *Units or ml[单位或毫升] 5、出院小结[discharge summary] Patient Name[病人姓名] Medical Record No.[病历号] Attending Physician[主治医生] Date of Admission[入院日期] Date of Discharge[出院日期] Pirncipal Diagnosis[主要诊断] Secondary Diagnosis[次要诊断] Complications[并发症] Operation[手术名称] Reason for Admission[入院理由] Physical Findings[阳性体征] Lab/X-ray Findings[化验及放射报告] Hospital Course[住院诊治经过] Condition[出院状况] Disposition[出院去向] Medications[出院用药] Prognosis[预后] Special Instruction to the Patient(diet, physical activity)[出院指导（饮食，活动量）]
Follow-up Care[随随访]6、住院/出院病历首页[Admission/dischargerecord]Patient name[病人姓名]race[种族]address[地址]religion[宗教]medical service[科别]admit（discharge）date[入院（出院）日期］Lengthof stay[住院天数]guarantorname[担保人姓名]nextofkinorpersontonotify[需通知的亲属姓名]relation to patient[与病人关系]previousadmitdate[上次住院日期]admittingphysician[入院医生]attendingphgsician[主治医生]admitting diagnosis[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]nosocomial infection[院内感染]consutants[会诊]Critical-No.of times[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]Clinical andpathological Dxconcur[临床与病理诊断符合率]Pre-andpost-operativeDxconcur[术前术后诊断符合率]
Follow-up Care[随随访] 6、住院/出院病历首页[Admission/discharge record] Patient name[病人姓名] race[种族] address[地址] religion[宗教] medical service[科别] admit (discharge) date[入院（出院）日期] Length of stay [住院天数] guarantor name [担保人姓名] next of kin or person to notify[需通知的亲属姓名] relation to patient[与病人关系] previous admit date[上次住院日期] admitting physician [入院医生] attending phgsician[主治医生] admitting diagnosis[入院诊断] final (principal) diagnosis[最终（主要）诊断] secondary diagnosis[次要诊断] adverse reactions (complications)[副作用（合并症）] incision type[切口类型] healing course[愈合等级] operative (non-operative) procedures[手术（非手术）操作] nosocomial infection[院内感染] consutants[会诊] Critical-No. of times[抢救次数] recovered-No. of times[成功次数] Diagnosis qualitative analysis[诊断质量] OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率] Clinical and pathological Dx concur[临床与病理诊断符合率] Pre- and post-operative Dx concur [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]recovered[治愈]improved[好转]notimproved[未愈]died [死亡]Dispositon[去向]home[家]againstmedicalad[自动出院]autosy[尸检]transferredto[转院到
Dx determined with in 24 hours (3 days) after admission[入院后24小时（3天）内确诊] Discharge status[出院状况] recovered[治愈] improved[好转] not improved[未愈] died [死亡] Dispositon[去向] home[家] against medical ad[自动出院] autosy[尸检] transferred to[转院到