[所有分类]如何写好病历.ppt

如何寫好病歷 新光醫院 神經科 陳威宏 醫師 住院病歷 (Admission Note) 主訴(Chief Compliant):描述病人目前的問題，由病人就醫的主要症狀和發生的期間兩部分，構成一句完整的句子。 過去病史(Past History):記載過去患過的疾病、動過的手術、服用的藥物，以及發生過的意外事故。 個人史(Personal History):個人以往的生活狀況，如嗜好、職業、婚姻以及習性等。 家族病史(Family History):主要在瞭解有無家族性的疾病，如糖尿病、高血壓、心臟病，具有遺傳性的疾病等。 目前病史(Present Illness):住院病歷中最重要的部分。 系統回顧(Review of System):作為全身各器官、系統功能和症狀的總評估。 身體檢查(Physical Examination):記載親自看到或動手檢查所發現到的狀況。 CHIEF COMPLAINTS Symptoms (NOT diagnosis), duration (for xx hours, days, weeks, months, years. NOT since ….) The descriptive word or phrase of the complaint must in patient’s own language. Example Chest pain (NOT angina), 2 hours Right side weakness (NOT right hemiplegia), 2 days Acute onset of double vision, 3 days Progressive edema in lower limbs, 1 month Progressive distal weakness in all limbs, 6 months Sudden onset of excruciating headache, 4 days ago Confusion and fever, 1 week Confusion for 1 week, and fever for 3 days PRESENT ILLNESS Who When Where How What Why 起 承 轉 合 Taking a History Who Sex Age Social history Past medical history Family history When Attack onset Duration Course Attack frequency Taking a History Where Location Symmetry Radiation How Quality Severity Associated features Why Aggravating or precipitating factors Relieving factors 起 Age, sex, background, relevant past history… Onset time: days, weeks, months or years before. Mode of onset: sudden, acute, insidious… Description of symptoms: how and where Example The patient, a female of xx and native of Taiwan, is a school teacher. The patient, a male of xx and native of Hunan, was a soldier before. The patient, a xx-year-old female, has had (hypertension, diabetes…) for xx years. She took OHA (anti-hypertensive medication…) for regular control… She did not receive any treatment before. Example This xx-year-old (man, woman, boy, girl) had been well until xx (days, weeks, months) before (earlier), when he (she) experienced a (sudden, acute, insidious) onset of… This xx-year-old (man, woman) with a x