4、输血申请单[Blood bank requisition form]
(1)reason for infusion[输血原因]
▲红细胞[packed red cells, wshed RBCs]:
*Hb<8.5 [血色素<8.5]
*>20% blood volume lost [>20%血容量丢失]
*cardio-pulmonary bypass with anticipated Hb <8[心肺分流术伴预计血色素
<8]
*chemotherapy or surgery with Hb <10[血色素<10的化疗或手术者]
▲全血[whole blood]:
massive on-going blood loss[大量出血]
▲血小板[platelets]:
*massive blood transfusion >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]
*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？]医.学 全,在.线,提供www.med126.com
*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/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]
•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]
