（课件）内科病历修改注意事项.pptVIP

內科病歷修改注意事項 陶宏洋臨床教師共識營 2007-01-20 病歷寫的好的關鍵 H P POMR (明白曉暢) SOAP (前後呼應) 病歷寫的好的特徵 病歷封面 病歷封面應有藥物過敏史的記載，藥物名稱及過敏表現症狀，日期及簽章。 過敏史的詢問不應只限制在第一次看診，而應時常詢問。 嚴重的藥品不良反應史，雖不一定屬過敏反應，也應記錄。(例 RIF hepatitis GOT GPT 1000..)　　 病歷首頁 醫囑 TPR sheet 入院病歷 入院病歷 入院病歷 入院病歷 入院病歷 入院病歷 入院病歷 入院病歷 Discharge Summary 診斷病名儘量不要縮寫，治療結果亦應敘述。 主診斷應是與此次住院主訴相關的診斷。 其他診斷的順序應按病情的時間順序、急迫性、嚴重度列出。 診斷的依據及治療狀況應在住院病程中敘述，重要的檢查檢驗及併發症應詳列。 出院指示應明確記載藥物藥名、劑量、用法、天數，注意事項，回診日期，診間及門診醫師等。 常見的錯誤英文病歷書寫(1) ?錯誤使用normal 或negative 例：Physical examination was normal (or negative).錯誤 應該寫為： Physical examination revealed no abnormalities. Results of physical examination were normal. No abnormalities were disclosed (found, noted,detected) on physical examination. 常見的錯誤英文病歷書寫(2) ?錯誤使用normal 或negative 例：Laboratory was negative. The biopsy was negative.錯誤 The ECG was negative.錯誤 應該寫為： Laboratory tests (studies) gave normal results. Laboratory tests showed normal values. Laboratory data were normal (or within normal limits. The result of the biopsy was negative. 常見的錯誤英文病歷書寫(3) R/O, rule out R/O（或rule out）的意思是“排除“。因此前提必須是有一個相對的診斷，然後須“排除“什麼疾病或是診斷。但是常見以下的寫法： Fever, R/O pneumonia。這麼寫的真正意思是，病人發燒，結果將肺炎認為是最有可能的診斷。但是讀起來卻是，排除肺炎。 應該寫為： Fever, suspect pneumonia; R/O viral infection (or drug fever)。 常見的錯誤英文病歷書寫(4) ? 常見的不當使用語詞 1. Liver cirrhosis, a tumor mass, seizure attack (贅述)。 2. Victim少用。如The patient is a victim of motor vehicle accident (MVA).可寫成The patient had an MVA。 3. Unfortunately少用。如Unfortunately, nausea, vomiting and abdominal pain developed since last night, and the patient was brought to ER for help. 4. According to the pt., 非According to the statement of the patient herself that.. 常見的錯誤英文病歷書寫(5) ? 常見的不當使用語詞(續) 5. The sputum culture yielded (grew) Sreptococcus pneumoniae. 非The sputum culture showed bacteria.; 另外Bacterial culture was positive for Streptococcus pneumoniae.亦可 6. During the hospitalization, 非During the period of admission… 7. The patient was diagnosed as having colon cancer. 或A diagnosis of colon cancer was made. 非Col