病歷的書寫
病歷的書寫
病歷的書寫
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Orders
T.P.R. Sheet
Admission Note
Progress Note
Consultation Note
Invasive Procedure Record
Operation Note
Informed Consent()
Discharge Summary
X
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Admission Orders
1.
Diagnosis
1.
2.
3.
4.
2.
Allergy
Shrimps (urticaria); penicillin (positive skin test
urticariaprobable anaphylactic shock)
3.
Condition
Critical or guarded
4.
5.
6.
Diet
Activity
Medications
7.
IV fluids
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Discharge Orders
Discharge this afternoon
Discharge tomorrow morning
Discharge against medical advice (discharge AMAAAD)
OPD F/U in 3 days; Referred back to Dr. Lins clinic
TPR sheet
TPRI/OBMdrainage
TPRNSAID
WBCCRP
seizure
TPR sheet
Admission Note
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Chief Complaints
Present Illness
Past History
Personal, social and occupational history
Family History
Review of Systems
Physical Examination
Image and Laboratory
Impression
Plan of management and treatment
Admission Note
Chief Complaints
Abdominal pain since last Sunday.
Progressive abdominal distention 4 days before (
prior to) admission.
Intermittent abdominal pain for 4 hours.
Sudden onset of sharp epigastric pain for 2 hours.
Admission Note
Present Illness
LMDlocal hospital
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1.-
2.
(
)
negative symptoms
history
3.
SKH
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Admission Note
Present Illness
Present illness
Admission Note
Past History
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Admission Note
()
()()
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Admission Note
Family History
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History taking
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Admission Note
Review of System
Past History
Present Illness
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Admission Note
Physical Examination
anemicpale
jaundiceicteric
eggsized, palm-sized
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Admission Note
Impression
Cirrhosis, alcoholic, Child class C;
Spleen laceration, Grade I, hemodynamic stable;
Old CVA, with right hemiplegia
ImpressionDifferential Diagnosis.
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Admission Note
Plan
To give iv fluids.
To give antibiotics
To give antihypertensives
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Progress Note
Problem-Oriented Medical Record (POMR)
Subjective-ObjectiveAssessment-Plan (S.O.A.P.) active
problem()SOAP
counter-sign ()
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SOAP
S (subjective): symptoms (chief complaints)
SKH
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Impression
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#1
Chest pain
S:___________
O:___________
A:___________
P:___________
#2
Upper GI bleeding
S.O.A.P.
#3
Arrhythmia
S.O.A.P.
SKH
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3.
surgery.
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6.
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9.
10.
fragment of 48.
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13.
14.
P: 1. OHI.
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Assessment
impression
1.
2.
DM type 2
3.
4.
Diarrhea
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Assessment / Plan ()
Assessment / Plan ( )
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Weekly Summary
Weekend summary
COPY
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Consultation Note
We sincerely request
Your nationally reputabel expertise,
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Secondary ()
/
*
:
1) acute congestive heart failure
2) acute myocarditis
1) aspiration pneumonia
2) ventricular tachycardia
SKH
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3. Hospital course
()
4. (Lab results)
positivepertinent
negative findings
SKH
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SKH
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IDP
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IDP
Issue
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IDP
Discussion
(1).
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IDP
Discussion
(2).
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IDP
Discussion
(3).
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IDP
Planning
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IDP
Issue
Discussion
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A
Plan
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Patient is a 62 years old female, his chief complaint is
abdominal pain.
The Patient is a 62 years old woman, her chief complaint is
abdominal pain.
chief complaint
1. The patient is a 62-year-old woman, and her chief
complaint is abdominal pain.
2. A 12-year-old girl complained of abdominal pain.
3. A 7-year-old boy was admitted to the hospital because of
abdominal pain.
4. A 40-year-old man presented with abdominal pain.
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(tense)
He had hypertension and still on three kinds of
antihypertensive.
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In last Saturday, his headache was suddenly
got worse.
Last Saturday, his headache suddenly got
worse.
The patient had an acute process
superimposed to his background conditions.
The patient had an acute process
superimposed on his background conditions.
: A 45 year-old woman of mitral stenosis..
: A 45 year-old woman with mitral stenosis.
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Cancer was told
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Acception note
acception acceptance
note on service note (off service
note)
Progression noteProgressive note.
Progress note
: Past history: Nil.
: Nil is a Latin word; it means nothing or
Zero. Non-contributory.
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()
Discharge diagnosis: R/O cancer.
: R/O (rule out)
R/O cancer
(work up) ruled in
ruled out
Discharge diagnosis: probable cancer
suspected cancer
sepsissepticemiabacteremia
sepsis ()
septicemia ()
bacteremia ()
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positive negative
The biopsy was negative. The exercise test
was positive. The ECG was negative.
positivenegative
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negative for,
unremarkable, non-contributory
The family history was nothing particular.
The family history was unremarkable (or
non-contributory).
Non-made
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cirrhosisliver cirrhosiscirrhosis of
the liver. Cirrhosisliver
seizure attack, seizureepileptic fit
a tumor mass a tumor, a mass (lesion)
fever of 38C (fever with) a temperature of 38C
The patient was AAD (against advice discharge, )
The patient was discharged AMA (against medical advice)
to be discharged AMA discharge AMA
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Victim
Victim
patientvictim
The patient is a victim of type 1 DM
diagnosed since 2 years ago.
The patient was diagnosed as having
type 1 DM two years ago.
: The patient is a victim of motor vehicle
accident (MVA).
: The patient had a MVA.
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Unfortunately
Unfortunately, the patient had..
unfortunatelysadlymiserablyunluckily
A test (or examination) was arranged
(performed), which showed
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Culture showed bacteria
showreveal
yield grow
The sputum culture showed Streptococcus
pneumoniae infection.
According to the statement of the patient
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admission
period
During the hospitalization
During the hospital stay
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A disease was diagnosed.
The patient was diagnosed as a disease.
as a disease
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Irregular control, Regular medication
irregular controlirregular medicationregular medicationThe
patient has hypertension for 10 years with irregular medications.
()()regular medication
The patient has had hypertension for 10 years, but he did not take medicine as ordered.
The patient has had hypertensive for 10 years, but he has not been taking medicine regularly.
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Ever
Everat anytime past or future,
always constantly
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Mentality clear
mentality
Consciousness () clear
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In vain
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The patient developed abdominal pain and high fever.
Abdominal pain and high fever developed.
Dear Dr. ; We
sincerely request; your expertise;
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According to
Examples
The patient stated (claimed, said) that he had
abdominal pain just after meals.
The patient suspected (thought) that he
acquired his infection during a journey to the
Mainland China one week ago.
According to the patients son, he was noted
disoriented in time about 2 weeks ago.
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Manifest, exhibit
Suffer, experience
()
Examples
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Admission to a hospital, be
hospitalized (admitted), enter
Be discharged, discharge,
leave a hospital
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Examples
The patient sought medical advice for the swelling of his scrotum.
He was admitted (hospitalized) because of chest discomfort and
palpitation for one day.
The patient visited and was told to have colon cancer.
A blood test was done (taken), and the result showed 50mg/dl of blood
sugar.
The patient underwent an emergent laparotomy and colon perforation
was noted.
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Healthy, energetic,
vigorous
Strong, robust
Examples
The patient had been in good health (had been well) until 2 weeks ago
when she had severe chest pain, which occurred suddenly after
paroxysmal cough.
This 50 y/o man had enjoyed an excellent health until one month ago
when he experienced occasional low abdominal pain.
The patient has been bed-ridden (confined to bed) with paraplegia since
the traffic accident happened to him one year ago.
The patient was afflicted with diabetes for many years.
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During admission
(hospitalization, hospital stay)
Examples
Severe abdominal pain and high fever before admission (prior to this entry,
hospitalization).
During the three months before entry, the patient experienced progressive
loss of weight and appetite.
The onset of abdominal pain can be dated back to one week ago.
During the admission, the patient was treated with antihypertensives.
The patient experienced an abrupt onset of chest pain and dyspnea.
He had swelling of the lower legs gradually (insidiously).
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Be located, be situated (in, at,
Be localized, be limited, be
restricted, locally
to
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Examples
The burning sensation was located (felt) in the left shoulder.
The reddish skin was localized (limited) to the right instep and
did not extent above the ankle.
The sharp pain started in the right flank and radiated to the
right hypochondrium and even down to the scrotum.
The pain began in epigastric area and then shift to right lower
quadrant of the abdomen.
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fluctuating
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Examples
Tarry stool persisted over the next five days.
For the past two weeks, the patient has had several
paroxysmal dyspnea, which usually occurred at night and
lasted for about 15 minutes.
Constipation and diarrhea came alternately (alternative
constipation and diarrhea).
The blood-tinged stool was noticed at least on two occasions.
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Examples
The epigastric pain gradually increased in severity.
The chest pain, localized mostly over the left lateral chest, decreased in
severity or was minimal when breath was held, but was aggravated by
inspiration.
The patient remained gravely ill after cholecystectomy, although his
jaundice and liver function were not deteriorated.
The patient suffered from vague (cramp) abdominal pain for one week.
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Examples
The patient had intermittent cough for more than 20 years, and began to
have a small amount of blood-tinged sputum in recent three months.
A hen egg-sized lump has been noted on the abdominal wall without
change in size or shape for the past ten years.
The patient loss his weight from 70 kg to 60 kg within 2 months.
Numerous pinhead-sized papules initially occurred over the chest,
increased rapidly in number and spread to the neck and face.
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Trigger, cause, precipitate,
influence, affect
Precede, antecedent
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Examples
The patient cannot recall any precipitating (provoking) factor of the attack.
The chest pain was induced by walking for about 10 minutes and
disappeared after taking a rest.
The cramping ache was present constantly in the lower abdomen,
unaffected (not influenced) by meals or bowel movement.
The patient had a tendency toward cold sweating and dizziness before
lunch, which could be relieved by taking a snack.
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Be accompanied by, be
complicated with (by), concur
Examples
Concurrently, the patient had abdominal pain and diarrhea, in
addition to vomiting.
Epigastric pain persisted and was unrelated to meals.
The chest pain was closely related to (associated with)
position, movement, and swelling.
The cough was followed by dyspnea and fainting attack few
minutes later.
The fracture of the left femur was complicated with
pulmonary embolism.
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On exertion, on exercise
On squatting
Climbing stairs
Trouble, difficult
Examples
The patient often felt dizzy when rose
suddenly from recumbent or sitting position.
The backache was mild on standing erect, and
could be partially relieved by bending forward.
The pain could be significantly decreased by
lying on his right decubitus.
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Progressing favorable, doing well,
make a favorable progress, relief,
progressively worsening, an
Examples
After the operation, the patient made a favorable progress.
The pain of ankle was relieved promptly after the patient took
the doctors prescription.
In spite of intensive management of his heart failure, the
patients consciousness got worse and was aggravated by
pneumonia.
The leg edema subsided gradually after the patient took
diuretics.
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