英文病歷寫作,英語病歷寫作模板

PATIENT HISTORY

病 史

A detailed patient history and physical exam form the foundation of patient evaluation and vital patient data that enables efficient, quality patient rounds.

一份詳細(xì)的病史和體檢是評估患者的基礎(chǔ)，也可為組織高質(zhì)量、高效率的查房提供重要的資料。

On the other hand, a poorly documented history and physical may leads to confusion, serious omission of vital data and inefficiency on patient rounds. In this age of modern technology with equipment such as CT, MRI and PET scanners, the history and physical exam seem to be slowly evolving into a relic of a past era! Both attending physicians as well as residents in training seem to rely more heavily on laboratory and imaging modalities than history to establish the diagnosis. “However no part of the patient evaluation is more essential to diagnosis than the patient history. The importance of skillful data collection is underscored by the widely accepted understanding that the medical history contributes 60% to 80% of the information needed for accurate diagnoses.” Thus to neglect the patient history denies the physician of a “vital” diagnostic tool.

另一方面，寫得差的病史和體檢可能會(huì)引起混淆，導(dǎo)致重要資料的遺漏和查房效率的低下。在這個(gè)具有現(xiàn)代化設(shè)備如CT、MRI、PET的年代里，病史和體格檢查似乎已慢慢地成為一種歷史遺物。無論是主治醫(yī)生或住院醫(yī)生都似乎越來越依賴于實(shí)驗(yàn)室和影像學(xué)檢查而不是病史來明確診斷。然而對診斷來說，沒有一種評估手段比病人的病史更重要。盡管普遍認(rèn)為病史可提供準(zhǔn)確診斷所需的60％一80％的信息，但有效地收集資料的技能仍被低估了。所以若忽略了患者的病史就意味著剝奪了醫(yī)生的一種最重要的診斷工具。

The basic outline structure for the patient history and physical exam usually includes the following:

l Identification: patient name, age, gender, race, and occupation

l Chief Complaint: (in the patient’s words)

l HPI: (history of present illness)

l PMHx: (past medical history)

l Medications: should include current meds as well as medication allergies

病史和體格檢查的基本框架內(nèi)容通常包括以下內(nèi)容：

l 身份證明：患者姓名，年齡，性別，種族和職業(yè)

l 主述：(用患者的話表達(dá))

l HPI：現(xiàn)病史

l PMHx：過去史

l 藥物史：包括現(xiàn)在使用的藥物以及藥物過敏史

l ROS: review of systems

l Social Hx.: includes family situation (married, divorced, single), habits; cigarettes, alcohol or illicit drug use, sexual behavior

l Physical Exam:

l Impression/Diagnosis:

l Treatment Plan:

l ROS：系統(tǒng)回顧

l 社會(huì)史：包括婚姻狀態(tài)(已婚、離婚、單身)、習(xí)慣、吸煙、飲酒或吸毒、冶游史

l 體格檢查：

l 診斷：

l 治療方案：

l Self- introduction: Upon arrival at the patient's bedside, the physician should first try to establish rapport with the patient by using “nonverbal cues” such as maintaining eye contact or extending a hand to shake the patient’s hand (if “culturally” acceptable). The physician or student should first introduce him or herself and state their reason for the visit. Also, they should ask the patient’s permission to interview them.醫(yī)學(xué).全在線www.gydjdsj.org.cn

l 自我介紹：到達(dá)病人床邊時(shí)，醫(yī)生應(yīng)通過非言語的方式如保持視線的接觸或伸手去和病人握手(如果風(fēng)俗上可以接受)來與病人建立融洽的關(guān)系。醫(yī)生或醫(yī)學(xué)生首先應(yīng)自我介紹并解釋來看病人的原因，并且應(yīng)在交流前取得病人的同意。

Here are a few specific points about each section of the history outline:

1. Identification -- This should include the patient's name, age, sex, race and occupation for example: “Mr. Jones is a 55 yr. Old Caucasian male who works as a farmer.” The patient’s name written in the history allows future interviewers to address the patient by his name which conveys a sense of patient respect. The age, race, sex and occupation are an important as many diseases are not only gender and age dependent, but may also occur more commonly in specific ethnic and occupation groups.

以下是病史相關(guān)部分的說明：

1. 身份證明--這應(yīng)該包括病人的姓名、年齡、性別、種族和職業(yè)。比如“瓊斯先生是一位55歲的白人男性，職業(yè)是農(nóng)民”。在病史中寫明患者的姓名有利于以后的人員用病人的姓名來和他打招呼，這樣會(huì)使病人產(chǎn)生一種受尊重感。年齡、種族、性別、和職業(yè)都非常重要，因?yàn)樵S多疾病不僅與性別和年齡有關(guān)，并且在特定的種族或職業(yè)人群中更為常見。

2. Chief complaint -- This should be written in the patient’s words. For example “chest pain” rather than “angina”. Also the duration of the chief complaint should be noted “chest pain for 1 hour”. Before moving on to the HPI, it would be appropriate to perform a “survey of problems” asking the patient if there are any other current problems bothering them. Once these have been listed, the interviewer can come back to the original Chief Complaint the patient presented with and obtain the details in the HPI. However “associated” symptoms should be descried in the HPI.

2. 主述--主述應(yīng)該用病人的語言來寫。比如“胸痛”而不是“心絞痛”。而且應(yīng)同時(shí)寫明主訴的時(shí)間如“胸痛1小時(shí)”。在開始采集現(xiàn)病史之前，應(yīng)補(bǔ)充問病人是否還有其他不適癥狀。一旦發(fā)現(xiàn)有其他癥狀應(yīng)補(bǔ)充到主訴中，并在現(xiàn)病史中詳細(xì)描述。但伴隨癥狀應(yīng)在現(xiàn)病史中描述。

3. HPI (History of Present Illness) --The history of the present illness is a more elaborate description of the patient’s chief complaint and is the most important structural element of the medical history. This section should give the following details about the chief complaint (s):

3. 現(xiàn)病史--“現(xiàn)病史是對病人主訴更為詳細(xì)的描述，是病史中最為重要的組成部分。”在這部分中應(yīng)對主訴從以下幾個(gè)方面加以詳細(xì)描述。

a. Detailed description of the “chief complaint”; “a dull crushing chest pain” including body location of the complaint.

b. A chronological history and sequence of the chief complaint.

c. What circumstances precipitated it: climbing stairs, emotional upset such as anger, or sexual intercourse.

d. What circumstances relieve it: resting for a few minutes.

a． 對“主訴”更為詳細(xì)地描述；如“壓榨樣胸部悶痛”，應(yīng)包括主訴的部位。

b． 主述的發(fā)展變化。

c． 誘因：如爬樓梯、情緒激動(dòng)，如發(fā)怒、性生活等。

d． 緩解因素：如休息幾分鐘、硝酸甘油。 醫(yī)學(xué) 全在.線提供

4. ROS (Review of Systems) -- This section is too often omitted. Although it is somewhat cumbersome to go through a “complete” review of systems and it may not be necessary to do so for “each” admission, at least one “complete” review of systems should be documented in the patient's medical record. For subsequent admissions the history could simply refer back to the “complete ROS” documented on a specified date. However, even with subsequent admissions, a minimum would be to include in the HPI a “pertinent” ROS of the organ - system of Chief complaint.

4. ROS(系統(tǒng)回顧)--很 多情況下這一部分被省略了。盡管對每個(gè)系統(tǒng)作一個(gè)完整的回顧有些麻煩，并且每次住院都這么做可能不一定必要，但是在病人的病史記錄中應(yīng)至少有一次完整的系 統(tǒng)回顧。此后的住院即可指明參考某年某日這份完整的系統(tǒng)回顧。但是即使在以后的住院病史中，至少應(yīng)在現(xiàn)病史中對主訴相關(guān)的器官系統(tǒng)作——系統(tǒng)回顧。

5. Social History -- This section is the most neglected section of the patient history performed in China. Vital information such as smoking history, use of alcohol or illicit drugs and sexual behavior can give invaluable clues to the diagnosis. Cigarette smoking is a risk factor for a vast array of diseases including cancer, coronary heart disease, COPD and GI diseases. In China, the prevalence of smoking among females is only about 5%. However, it's gradually increasing among young females. Thus physicians frequently forget to ask females about their smoking history. Also documentation of the patient’s marital status (divorced) and family situation may give clues to the early diagnosis of anxiety or depression. A brief family medical history should also be included if not already mentioned in the HPI.

5. 社會(huì)史--在中國的大病史中這一部分是最常被忽略的部分。重要的信息如吸煙史、飲酒或吸毒史、性行為對診斷常能提供非常重要的線索。吸煙是很多疾病的危險(xiǎn)因素包括癌癥、冠心病、COPD和消化系統(tǒng)疾病。在中國，女性吸煙率僅為5％。但在青年女性中在逐漸升高。而對于女病人來說，醫(yī)生常常會(huì)忘記問吸煙史。同時(shí)寫明婚姻狀況(離婚)和家庭狀況對于早期診斷焦慮或抑郁也有幫助。如果在現(xiàn)病史未提到，則應(yīng)對家族史做一簡單的闡述。

Although we’ve described a nice, neat “outline” for the patient history, when the medical student first begins to interview take a history, he quickly discovers that fitting patient’s responses into a “neat” history and physical outline is indeed a challenge and requires much patience and practice! Patients have not been told their responses are to “fit” into a structured format! When asked a specific question by the medical student/physician interviewer, they may assume they should give as much information as possible, thus the interviewer is forced to “sift” through their response and retain only the pertinent data for the medical record.

盡管我們對如何采集病史提出了—個(gè)清晰明了的框架，但是當(dāng)醫(yī)學(xué)生們第—次去采集病史時(shí)．他們很快會(huì)發(fā)現(xiàn)把病人的反應(yīng)歸納到—個(gè)清晰明了的框架中去并不是一件易事。這需要耐心和實(shí)踐。病人們并不知道他們的回答要被納入到—個(gè)結(jié)構(gòu)化的表格中去!當(dāng)醫(yī)學(xué)生或醫(yī)生問及一個(gè)特定的問題時(shí)，病人會(huì)認(rèn)為應(yīng)該提供盡可能多的信息，所以采集病史者不得不從病人的回答中篩選內(nèi)容，僅保留與病史相關(guān)的部分。

In summary, the patient history is the most important aspect of patient evaluation as it guides the physician team’s decisions concerning diagnostic work up and formulation of a treatment plan. As mentioned the medical history contributes more towards the diagnosis than any other test (60% to 80% of the information needed to make the diagnosis). Further it can help to establish rapport where the patient not only learns to trust their physician but also is more likely to heed their advice.

總之，病史對于病人的評估來說是最為重妥的面，因?yàn)樗�指�?dǎo)著醫(yī)療小組制定診療方案。正如前面所述，病史比其他檢查提供更多有助于診斷的信息(60％一80％診斷所需的信息)。而且有助于建立融洽的醫(yī)患關(guān)系，因?yàn)椴粌H會(huì)使病人信任醫(yī)生，而且更會(huì)使他們聽從醫(yī)生的建議。