病历格式与范本.pdf

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1、十一、病歷格式與範本神經疾患相關病歷格式與範本（1）中樞系統損傷評估（2）脊髓損傷評估範例一：腦中風初評範例二：腦中風結案小兒疾患相關病歷格式與範本（1）兒童物理治療評估報告（2）病房兒童物理治療（3）新生兒評估（4）中文版新生兒神經行為評估量表範例一：一般發展遲緩（含IPP）範例二：腦性麻痺（含IPP）範例三：新生兒範例四：病房兒童物理治療骨科疾患相關病歷格式與範本（1）肌肉骨骼疾患評估（2）PhysicalTherapyforShoulderjoint（3）PhysicalTherapyAssessmentfo

2、rLowBackPain（4）PhysicalTherapyAssessmentforCervicalSyndrome(5)病房骨科物理治療評估範例一：肩部疾患心肺疾患相關病歷格式與範本(1)胸腔疾患評估(2)呼吸循環物理治療每日紀錄(3)復健部物理治療心肺疾病運動訓練病患狀況紀錄表(4)復健部冠狀動脈手術臨床路徑物理治療計畫表(5)復健部心房/心室中膈缺損手術(年齡大於10歲)臨床路徑物理治療計畫表範例一：CABGI範例二：CABGⅡ範例三：LungResection範例四：CardiacRehabiltatio

3、n範例五：COPD44神經疾患相關病歷格式與範本（1）中樞系統損傷評估國立台灣大學醫學院附設醫院復健部物理治療報告單(中樞神經系統損傷評估)病歷號姓名床號第頁I.BasicData:□InitialNoteDiagnosis:□AcceptanceNoteAge:y/oSex:Height:_____cmWeight:_____kg□SummaryNote□DischargeNoteHomeenvironment:Tel:PTbeginson:II.BriefHistoryandLabResults:III.Phy

4、sicalExaminations:Consciousness:Mentality:JudgmentOrientationMemoryAbstractthinkingCalculationCommunication:Vision:homonymoushemianopia:LR－neglect:LR－Facialpalsy:LR－/mildmoderatesevere/centralperipheralMuscletone:ROM/pain/Subluxation:BrunnstromstageRUE-P:RUE-D

5、:RLE:(I~VI)LUE-P:LUE-D:LLE:Musclestrength:RUE:P/D-RLE:P/D-LUE:P/D-LLE:P/D-Sensation:Lighttouch□RUE-P_____□RUE-D_____□RLE_____(1=intact,□LUE-P_____□LUE-D_____□LLE_____2=impaired,Proprioception□RUE-P_____□RUE-D_____□RLE_____3=absent)□LUE-P_____□LUE-D_____□LLE___

6、__Coordination:normalimpairedN/TFNFtest:L____secR____sec(5repetitions)HKHtest:L____secR____sec(5repetitions)tremor:－intentionalrestingRUERLELUELLEdysdiadokokinesia－RUERLELUELLEdysmetria－RUERLELUELLEneurologicallevel/miscellaneous:45Functionalstatus:(key:Indepe

7、ndent,Supervision,closeguard,contactguard,minimal,moderate,maximal,Assistance,verbalcueingexample:minAof1plusmodverbalcueing)rolling:R:L:supine←→sit:sit←→stand:chair←→bed:sittingbalance:static:□Poor□Fair□Gooddynamic:□Poor□Fair□Goodsupported:+－;secleantoRL－,los

8、ebalanceto________________sidestandingbalance:static:□Poor□Fair□Gooddynamic:□Poor□Fair□Gooddevice(support):Romberg:＋－,EOsec,ECsec;feetapartcmOnelegstance:leantoRL－,losebalancetosid