怎样写英文病历.doc

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1、Howtowritepatient'scasehistory怎样写英文病历PATIENTHISTORY病史Adetailedpatienthistoryandphysicalexamformthefoundationofpatientuationandvitalpatientdatathatenablesefficient,qualitypatientrounds.一份详细的病史和体检是评估患者的基础，也可为组织高质量、高效率的查房提供重要的资料。Ontheotherhand,apoorlydocumentedhistoryand

2、physicalmayleadstoconfusion,seriousomissionofvitaldataandinefficiencyonpatientrounds.InthisageofmoderntechnologywithequipmentsuchasCT,MRIandPETscanners,thehistoryandphysicalexamseemtobeslowlyevolvingintoarelicofapastera!Bothattendingphysiciansaswellasresidentsintraini

3、ngseemtorelymoreheavilyonlaboratoryandimagingmodalitiesthanhistorytoestablishthediagnosis.“Howevernopartofthepatientuationismoreessentialtodiagnosisthanthepatienthistory.Theimportanceofskillfuldatacollectionisunderscoredbythewidelyacceptedunderstandingthatthemedicalhi

4、storycontributes60%to80%oftheinformationneededforaccuratediagnoses.”Thustoneglectthepatienthistorydeniesthephysicianofa“vital”diagnostictool.另一方面，写得差的病史和体检可能会引起混淆，导致重要资料的遗漏和查房效率的低下。在这个具有现代化设备如CT、MRI、PET的年代里，病史和体格检查似乎已慢慢地成为一种历史遗物。无论是主治医生或住院医生都似乎越来越依赖于实验室和影像学检查而不是病史来明确诊

5、断。然而对诊断来说，没有一种评估手段比病人的病史更重要。尽管普遍认为病史可提供准确诊断所需的60％一80％的信息，但有效地收集资料的技能仍被低估了。所以若忽略了患者的病史就意味着剥夺了医生的一种最重要的诊断工具。Thebasicoutlinestructureforthepatienthistoryandphysicalexamusuallyincludesthefollowing:Identification:patientname,age,gender,race,andoccupationChiefComplaint:(int

6、hepatient’swords)HPI:(historyofpresentillness)PMHx:(pastmedicalhistory)Medications:shouldincludecurrentmedsaswellasmedicationallergies病史和体格检查的基本框架内容通常包括以下内容：身份证明：患者姓名，年龄，性别，种族和职业主述：(用患者的话表达)HPI：现病史PMHx：过去史药物史：包括现在使用的药物以及药物过敏史ROS:reviewofsystemsSocialHx.:includesfamily

7、situation(married,divorced,single),habits;cigarettes,alcoholorillicitdruguse,sexualbehaviorPhysicalExam:Impression/Diagnosis:TreatmentPlan:ROS：系统回顾社会史：包括婚姻状态(已婚、离婚、单身)、习惯、吸烟、饮酒或吸毒、冶游史体格检查：诊断：治疗方案：Self-introduction:Uponarrivalatthepatient'sbedside,thephysicianshouldfir

8、sttrytoestablishrapportwiththepatientbyusing“nonverbalcues”suchasmaintainingeyecontactorextendingahandtoshakethepatient’shan