病历书写(英文)

,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,HISTORY RECORD,What is history record,The clinical record documents the patients history and physical findings.It shows how clinicians assess the patient,what plans they make on the patients behave,what actions they take,and how the patient responds to their efforts.,Importance of history record,1.Diagnosis and treatment purpose,An accurate,clear,well organized record,reflects and facilitates sound clinical thinking.,It leads to good communication among the,many professionals who participate in caring,for the patient,2.Teaching and research purpose,3.Medicolegal purposes,How to make a good history,record,When creating a record,you do more than simply make a list of what the patient has told you and what you have found on examination.You must review your data,organize them,evaluate the importance and relevance of each item,and construct a clear,concise,yet comprehensive report.,How to make a good history,record,1.Order is imperative,2.Keep items of history in the history,3.Describe specifically any pertinent negative information,4.Data not recorded are data lost,5.Use short words instead of long and probably fancier ones when they mean the same thing,6.Be objective,7.You should write the record as soon as possible,Basic requirement for the,history record,1.To be well organized and canonical,2.No much erasion and gride could be done in the history record,3.To be objective and accurate,4.Using professional term to record instead of folksay,5.Remember to have your signature,A.Outline of case record,1.Biographical data,Biographical information of patient should include his full name,age(date of birth),sex,race,occupation,nationality,marital status and permanent home address.Also,the date of admission,the time at which you took the history,the source of history and estimate of reliability should be involved.,2.chief complaint,The chief complaint consists of main symptom(s)and duration.It should constitute in a few simple words the main reasons why the patient consulted doctor and should be state as nearly as possible in the patients own wards.In general,the chief complaint should include age,sex,complaint,and duration of the complaint.It should no included diagnostic terms or disease entities.For example:”This 70-year old man has had short breath for a week.”,3.History of present illness(HPI),The history of present ill ness should be a well-organized,sequentially developed elaboration of his chief complaint(s)on its various characteristics:date of onset,character of complaint,mode of onset,course and duration,location,relationship to other symptoms,bodily function and activities,exacerbation and remissions,and effect of treatment.,4.Past history(PH),It should include a review of all past ill nesses,surgical procedures,and injuries,and allergy history(medicine,food),which are particularly related to the present illness.,5.Review of system(ROS),The purpose of sys tem review is twofold:a thorough evaluation and a double check prevent omission of significant data relative to the present illness.The review is a comprehensive account of all complaints referable to each body system progressing in a logical manner from the head toward the feet,including respiratory system,cardiovascular system,digestive system,Urinary system,hemopoietic system,endocrine system,nervous system and skeletal system.,6.Personal history,(social and occupational history)It includes personal habits(smoking,alcohol drinking),business life,sex life,occupation(exposure to certain irritating agents),condition of work.,7.Marital history,It includes data concerning the health of mate,sexual adjustment,the number of children and their Physical status,and the general social adjustment within the family.,8.Menstrual history,(for female patients),Age of onset,interval between periods,duration,amount and character of flow,concomitant symptoms,date of last menstruation,age of menopause.,9.Childbearing,(reproductive)history,Age and date of pregnancy(ies)and childbirth(s).Date of artificial or natural abortions,stillbirths,operative delivery,puerperal fever.Method of family planning,the possible factors of infertility(also for male patients).,10.Family history(FH),The health status of the patients family(mother,father,siblings and children)and if died,the age and cause of death should be recorded,such as diabetes,hypertension,cancer,obesity,allergic disorders,coronary artery disease and mental illness.,11.Physical examination(PE),The recording of Physical examination should follow a logical sequence as follows:vital signs,general status,skin,nodes,head,neck,chest,lungs,heart and blood vessels,abdomen,genitalia,rectum,spine and extremities,nervous reflexes.,12.Laboratory tests and instrumental examination,The findings of them onkly serve to confirm what you have found on history and Physical examination.The routine laboratory studies include blood,urine and stool tests,electrolytes,X-rays and ECG.,13 Summary,14.Prim