医学英语课件出院小结.ppt

Medical English Writing Clinical Reports Aims for Students To know the format of the discharge summaries; To understand the language features of the discharge summaries; To master the special language structures of the discharge summaries; To know how to write a discharge summary. Clinical Reports 1. Radiology Reports 2. Operative Reports 3. Discharge Summaries 4. Consultation (a meeting with an expert or professional, such as a medical doctor, in order to seek advice ) 5. Autopsy Reports A discharge summary is a clinical report prepared by medical or mental health practitioners when a patient is ready for discharge from a hospital or care facility. The discharge summary informs outpatient medical or mental health workers about services provided by the inpatient facility: admitting complaint, diagnoses, medications, treatments, and recommendations for outpatient follow-up services. The discharge summary should include all information pertinent to the ongoing treatment of the patient and the patients condition. Discharge Summaries 1. Present illness; 2. Past medical history; 3. Physical examination; 4. Laboratory data; 5. Hospital course; 6. Discharge diagnosis; 7. Discharge medications Discharge Summaries 1. Presenting illness 1.1. Language Features In this part, the general condition, the diseases and the treatment are described in past tense. E.g. The patient is a 66-year-old white male who was admitted for adenocarcinoma (腺癌） of the esophagogastric junction, with extension to esophagus and periaortic nodes. 1. Presenting illness adeno+carcinoma 1.2. Special Language Structures 1). This was the second hospital admission for this 50-year-old white female, with approximately a 25 year history of intermittent and recently progressive asthma. occurring at irregular intervals; not continuous or steady 1. Presenting illness 2) This 60-year-old male has a 10 year history of chronic lymphocytic leukemia, only becoming symptomatic one month prior to admission. 1.