英文病歷寫(xiě)作-醫(yī)療記錄回顧

MEDICAL RECORD REVIEW

醫(yī)療記錄回顧

A detailed, current medical record can be an invaluable asset for patient evaluation. The patient's “old” medical records should be thoroughly reviewed at the time of admission to develop a “framework” for the current medical history and history of present illness (HPI). Often this information is vital in understanding the patient’s immediate condition.

A periodic review of the initial history and physical exam　record is useful to remind the team members as well as to orient　new team members concerning the patient’s current problems. Often it’s helpful to review the patient’s “active” problem list each day when making rounds.

一份詳細(xì)的當(dāng)前病歷對(duì)患者的評(píng)估來(lái)說(shuō)是一種無(wú)價(jià)的財(cái)富。在入院時(shí)對(duì)病人的舊病歷進(jìn)行全面的回顧有助于建立現(xiàn)病史的框架。通常這些信息對(duì)于理解病人目前的情況是很重要的。

定期回顧原始病史和體檢記錄能幫助醫(yī)療小組成員以及新成員記住病人目前的問(wèn)題。此外，每天查房時(shí)回顧病人目前的問(wèn)題也很有幫助。

When recording the history and physical, the physician should follow several rules:

1. Record all pertinent data.

2. Avoid extraneous data.

3. Use common terms.

4. Avoid nonstandard abbreviations.

5. Be objective.

6. Use diagrams or pictures when indicated.

All too often a review of the nurses’ notes is neglected. Such information allows the clinician to follow patient progress during the previous 24 hrs. period. Particular note should be made of the vital signs; blood pressure, pulse, body temperature and respirations.

當(dāng)記錄病史和體檢情況時(shí)，醫(yī)生們應(yīng)遵循以下幾個(gè)原則：

1. 記錄所有相關(guān)資料。

2. 避免無(wú)關(guān)的資料。

3. 使用普通的術(shù)語(yǔ)。

4. 避免使用不標(biāo)準(zhǔn)的縮寫(xiě)。

5. 要客觀。

6. 必要時(shí)可使用示意圖說(shuō)明。

很多情況下護(hù)理記錄常常會(huì)被忽略。而護(hù)理記錄可給醫(yī)生提供過(guò)去24小時(shí)內(nèi)病人的病情變化，其中應(yīng)特別記錄生命體征包括血壓、脈搏、體溫和呼吸。

Also fluid intake and urine output is often recorded and should be noted and reported on rounds. As the team evaluates the patient each day on rounds, detailed patient information will promote a more rational approach to patient care. If the nurse records an unusually high or low BP or pulse, this should be re - checked by the physician.

此外，還應(yīng)記錄攝人液體量及尿量以便在查房時(shí)報(bào)告。醫(yī)療小組每天查房時(shí)，獲得病人的詳細(xì)信息有助于制定更合理的診療方案。當(dāng)護(hù)士記錄到血壓或脈搏出現(xiàn)異常的增高或降低時(shí)，應(yīng)由醫(yī)生重新檢查。

Other important information sought from the nurses notes include any recorded incidents during the last 24 hrs, such as record of pain episodes, GI distress such as vomiting or diarrhea, febrile episodes or episodes of confusion. Since the nurse spends much more time at the patient's bedside than the physician, her monitoring and report of the patient's condition is extremely valuable and should never be overlooked. The nurse must be respected and treated with courtesy, as she is an integral member of the health care team who can often provide valuable information and provide invaluable assistance in care of the patient.

護(hù)理記錄可以提供的其他重要信息包括：過(guò)去24小 時(shí)內(nèi)記下的任何事件如疼痛的發(fā)作、胃腸道不適如嘔吐或腹瀉、發(fā)熱或意識(shí)模糊發(fā)作。由于護(hù)士在病人床邊的時(shí)間比醫(yī)生更長(zhǎng)，所以她們對(duì)病人的觀察和記錄具有非 常重要的價(jià)值，不應(yīng)被忽視。應(yīng)該尊重并禮貌地和護(hù)士相處，因?yàn)樗齻円彩轻t(yī)療小組中不可缺少的一員，常能在醫(yī)療服務(wù)中提供重要的信息和幫助。

In each patient’s medical chart, a “Problem List” should be recorded. This lists each problem separately for example, (1) Pneumonia, (2) CHF, (3) Hypertension. A progress note should be written for each “active” problem.

Detailed daily progress notes recorded in the patient's medical record are valuable for patient assessment. Such a record is helpful for consultants, attending physicians and nurses as it enables them to ascertain the patient’s progress. When writing progress notes, it's helpful to follow the SOAP format.

在每一位病人的病歷中應(yīng)有一份問(wèn)題列表。每個(gè)問(wèn)題應(yīng)單獨(dú)列出，如(1)肺炎，(2)充血性心力衰竭，(3)高血壓病。對(duì)每個(gè)“活動(dòng)”的問(wèn)題都應(yīng)在病程記錄中記錄。

每天在病歷中詳細(xì)記錄的病程記錄對(duì)于病人的評(píng)估來(lái)說(shuō)非常有價(jià)值。這種記錄能幫助顧問(wèn)醫(yī)生、主治醫(yī)生和護(hù)士了解病人病情的發(fā)展變化。當(dāng)書(shū)寫(xiě)病程記錄時(shí)，遵循SOAP的格式會(huì)比較有幫助。

S = subjective -- This section usually includes a description of patient complaints and symptoms. These should be recorded in the patient’s own words.

O = objective -- This section records pertinent patient physical exam findings including vital signs as well as pertinent recent x- ray, lab and biopsy data. Avoid the notation “vital signs – stable”. A blood pressure of 100/60 in a patient with a history of hypertension may represent relative “hypotension” with significant hemodynamic consequences.

S = subjective主觀部分--這部分通常包括對(duì)病人主訴和癥狀的描述，應(yīng)該用病人自己的語(yǔ)言來(lái)表達(dá)。

O = objective客觀部分--這部分記錄病人的體格檢查結(jié)果，包括生命體征，以及相關(guān)的最近的X線檢查、實(shí)驗(yàn)室檢查和活檢資料。避免書(shū)寫(xiě)“生命體征平穩(wěn)”。對(duì)一位有高血壓病史的病人來(lái)說(shuō)，100／60的血壓就可能代表相對(duì)的“低血壓”，可能會(huì)導(dǎo)致嚴(yán)重的血流動(dòng)力學(xué)后果。

A-- assessment --This section is often the most neglected in the progress note. However, it is perhaps the most important as decisions regarding selection of diagnostic test and treatment plans are based upon the assessment. A differential diagnosis should be included in this section for problems that have not been clearly elucidated.

P =plan--In this section is recorded the treatment plan including estimated length of treatment, and discharge plans.

A = assessment評(píng)估--這一部分在病程記錄中最常被忽略。然而這部分卻可能是最重要的，因?yàn)檩o助檢查的選擇和治療方案的制訂常基于對(duì)病人的評(píng)估而作出。當(dāng)有未明確的疾病情況時(shí)，這一部分應(yīng)包括鑒別診斷。

P = plan計(jì)劃--這部分記錄治療計(jì)劃包括預(yù)計(jì)的治療時(shí)間和出院計(jì)劃。

Following is a sample progress note for a pneumonia patient:

S. Patient c/o cough productive of blood - streaked sputum. He denies any dyspnea.

O: Maximum temp. 38. 5, BP 90/60 R 24, pulse 100, 02 sat 91%

Lung auscultation – rt. mid-lung crackles posterior

Chest X-ray -- resolving rt. middle lobe infiltrate

Sputum and blood cultures -- pending

以下是一位肺炎病人的病程記錄樣本：

S：病人咳嗽、咳痰，痰中帶血絲，否認(rèn)有呼吸困難

O：最高體溫38.5oC，BP 90／60，R 24，脈搏100，O2飽和度91％

肺部聽(tīng)診--右中肺聞及濕羅音

胸透片--右中肺滲出在吸收

痰培養(yǎng)和血培養(yǎng)--尚無(wú)結(jié)果

A:

1. RML pneumonia -- suspect possible bronchial obstruction from tumor

2. COPD

3. Nicotine dependence

P:

1. Continue antibiotics -- Azithromycin and Ceftriaxone

2. Bronchoscopy tomorrow

3. Nicotine patch

A：

1. 右中肺炎--可能由腫瘤阻塞支氣管引起

2. 慢性支氣管炎

3. 尼古丁依賴

P：

1. 續(xù)用抗生素--阿奇霉素和頭孢曲松

2. 明行支氣管鏡檢查

3. 尼古丁貼片

There should be a separate SOAP progress note for each “active” problem. An “active” problem is one that requires treatment during the current hospitalization. For example a patient may be admitted with CHF and GI bleeding. Each day both problems should be evaluated at the bedside reviewing the history, physical findings and recent lab data. These data should all be recorded in two separate progress notes addressing each specific problem.

對(duì)每個(gè)“活動(dòng)”的問(wèn)題都應(yīng)有獨(dú)立的S()AP病程記錄。所謂“活動(dòng)”的問(wèn)題是指目前住院需要治療的問(wèn)題。例如一位病人可能因?yàn)槌溲�性心力衰竭�?a class="channel_keylink" href="/edu/200904/108887.shtml" target="_blank">消化道出血住院。每天在床邊應(yīng)通過(guò)回顧病史、體檢和最近的實(shí)驗(yàn)室檢查資料來(lái)評(píng)估這兩個(gè)問(wèn)題。應(yīng)在兩個(gè)不同的病程記錄里記錄這些資料來(lái)說(shuō)明每個(gè)問(wèn)題。 醫(yī)學(xué) 全在.線提供

Progress notes must be current; not only should their date be recorded, but ideally the time of day recorded. Occasionally with critically ill patients, it will be necessary to record several progress notes during the same day. Recently, a medical student informed me that she observed a group of medical students busily writing progress notes in charts of patients that had been previously discharged two weeks prior. Such practice is not only useless, but may be “l(fā)egally” challenged in court. It is the attending physician’s responsibility to ensure that his junior staff record progress notes daily. The attending physician should review these notes regularly to ensure compliance.

病程記錄應(yīng)及時(shí)記錄，不僅日期應(yīng)寫(xiě)明，最好也寫(xiě)明時(shí)間。遇到危重病人時(shí)，同一天里可能要記好幾次病程記錄。最近有位醫(yī)學(xué)生告訴我有些醫(yī)學(xué)生在忙碌地補(bǔ)寫(xiě)2周前已經(jīng)出院病人的病程記錄。這種做法不僅沒(méi)用，而且可能會(huì)受到法律的制裁。主診醫(yī)生應(yīng)負(fù)起責(zé)任，督促低年資醫(yī)生每天完成病程記錄。主診醫(yī)生應(yīng)定期檢查病程記錄以確保按時(shí)完成。

Operative or procedure notes must also be written or dictated immediately post- op in order to allow ICU physicians or others involved in the patient's care to understand the surgical procedure and any possible intraoperative complications. They should include the following: 醫(yī).學(xué) 全,在.線,提供www.med126.com

l Date and time:

l Procedure done:

l Indications:

手術(shù)和操作記錄應(yīng)在完成后及時(shí)記錄，以使ICU醫(yī)生或其他醫(yī)務(wù)人員了解手術(shù)過(guò)程和術(shù)中可能發(fā)生的并發(fā)癥。記錄應(yīng)包括：

l 日期和時(shí)間：

l 所做的手術(shù)或操作：

l 適應(yīng)證：

l Patient consent: Document that the indications, risks and alternative treatments were explained to the patient or responsible family member. Note that the patient was given a chance to ask questions and that the patient consented to the procedure in writing.

l Lab tests: Pertinent labs--protime- INR, PTT, CBC

l Anesthesia:

l Description of Procedure: Describe the procedure, including sterile prep, anesthesia method, patient position, devices used, anatomic location of procedure, and outcome.

l 病人的同意書(shū)：說(shuō)明已把手術(shù)指征、風(fēng)險(xiǎn)和可選的其他治療方法向病人或負(fù)責(zé)的家屬講明。注意應(yīng)給病人提問(wèn)的機(jī)會(huì)，取得書(shū)面同意。

l 實(shí)驗(yàn)室檢查：相關(guān)的如PT—INR、PTT、CBC

l 麻醉：

l 手術(shù)過(guò)程描述：描述手術(shù)過(guò)程，包括消毒、麻醉方式、病人體位、所用的器械、手術(shù)的解剖定位和結(jié)果。

The final progress note prior to discharge should be a “discharge note”. It should include:

l Date/time:

l Diagnoses:

l Treatment:

l Studies Performed:

l Discharge medications:

l Follow - up Arrangements: (6)

Within one week of discharge, a discharge summary should be prepared that includes the following information:

l Patient's name and medical record number:

出院前的最后病程記錄應(yīng)是一個(gè)“出院錄”。它應(yīng)該包括：

l 日期和時(shí)間：

l 診斷：

l 治療：

l 做過(guò)的檢查：

l 出院帶藥：

l 隨訪計(jì)劃：

出院后1周內(nèi)，應(yīng)完成出院小結(jié)，包括下列信息：

l 病人的姓名和病歷號(hào)碼：

l Date of admission:

l Date of discharge:

l Admitting diagnosis:

l Discharge diagnosis:

l Name of attending physician or team responsible for patient:

l Surgical or other procedures performed:

l Diagnostic tests performed:

l Brief history, pertinent physical exam and lab data:

l Hospital course:

l Patient’s condition at discharge:

l Discharge plan including follow- up appointment:

l Discharge medications:

l Problem list including all active and past problems:

l 入院日期：

l 出院日期：

l 入院診斷：

l 出院診斷：

l 主診醫(yī)生姓名或負(fù)責(zé)醫(yī)療小組名字：

l 做過(guò)的外科手術(shù)或操作：

l 做過(guò)的檢查：

l 簡(jiǎn)短病史、相關(guān)體檢和實(shí)驗(yàn)室資料：

l 住院過(guò)程：

l 病人出院時(shí)的身體狀況：

l 出院計(jì)劃包括隨訪安排：

l 出院帶藥：

l 所有當(dāng)前和既往疾病的列表：

The discharge summary is extremely valuable for follow – up care both to the physician who will see the patient in the outpatient clinic and the admitting team who may admit the patient in the future.

出院小結(jié)對(duì)病人出院后看門診醫(yī)生和今后再次住院醫(yī)療小組的隨訪很有價(jià)值。

When a patient is re - admitted, the old chart should be immediately obtained from the medical records dept. even while the patient is still in the E. IL A procedure and policy must be implemented by the hospital administration that allows access to medical records even during the evening and night. The value of an old chart and especially prior discharge summaries cannot be overemphasized. Often the clue to the patient's current diagnosis may be related to prior illnesses recorded in the old chart. The old chart should accompany the patient from the ER to the patient ward where he's admitted. Each physician or consultant involved in the patient's care must review the old chart taking special note of the discharge summary. The prior medical record is also valuable for comparison of current data with previous data; for example an old EKG that remains unchanged may help to rule out an acute myocardial infarction. Special note should be made of prior drug reactions and complications associated with procedures.

當(dāng) 病人再次入院時(shí)，應(yīng)能立即從病案室調(diào)取舊病歷，即使病人尚在急診室。醫(yī)院管理部門應(yīng)建立一種程序和政策保證夜間也能獲得病歷。舊病歷尤其是既往的出院小結(jié) 的價(jià)值無(wú)論怎么強(qiáng)調(diào)都不過(guò)分。病人目前的診斷常常與舊病歷中記錄的既往疾病相關(guān)。舊病歷應(yīng)伴著病人從急診室送人病房。參與病人診療過(guò)程的每位醫(yī)生都應(yīng)回顧 舊病歷尤其是出院小結(jié)。舊病歷對(duì)于比較現(xiàn)在的資料與過(guò)去的資料也有參考價(jià)值，比如此次EKG與既往相同可除外急性心肌梗死。還應(yīng)特別注意既往藥物反應(yīng)和手術(shù)伴隨的并發(fā)癥。