1、抗生素医嘱[Antibiotic order]
•Prophylaxis [预防性用药] Duration of oder[用药时间] 24hr
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] 72hr
Cultures ordered[是否做培养]
•Documented infection[明确感染]
Site and organism[部位和致病菌] 5days
•Other[其他]
Explanation required [解释理由] 24hr
•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[测生命体征]
•I / O [记进出量]
•Allergies[过敏]
3、住院病历[case history]
•Identification [病人一般情况]
Name[性名]
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 Aystems[系统回顾]
General[概况] 医学全在线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]
*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]