医院英文病历标准格式范例汇总.docxVIP

医院英文病历标准格式范例汇总

在医疗实践中，一份规范、清晰、详尽的英文病历不仅是医疗质量的体现，更是保障医疗安全、促进医患沟通、实现医疗信息共享的关键。本文旨在汇总医院常用英文病历的标准格式与范例，为临床工作者提供实用参考，助力提升病历书写的规范性与专业性。

一、PatientIdentification(患者识别)

此部分为病历首页的核心信息，用于准确唯一地标识患者。

Content:

*FullName:[PatientsFullLegalName]

*MedicalRecordNumber(MRN):[Hospital-assignedMRN]

*DateofBirth(DOB):[MonthDD,YYYY]

*Age:[XX]years

*Gender:[Male/Female/Other/Unknown]

*Race/Ethnicity:[Asself-identified,e.g.,Caucasian,AfricanAmerican,Hispanic,Asian,etc.]

*MaritalStatus:[e.g.,Single,Married,Divorced,Widowed]

*Address:[ResidentialAddress]

*ContactPhoneNumber:[PrimaryPhoneNumber]

*EmergencyContact:[Name,Relationship,PhoneNumber]

*DateofAdmission/Encounter:[MonthDD,YYYY]

*AdmittingService/Clinic:[e.g.,InternalMedicine,CardiologyClinic]

*AttendingPhysician:[Dr.FirstNameLastName]

Example:

*FullName:JohnMichaelSmith

*MedicalRecordNumber(MRN):ABC12345

*DateofBirth(DOB):January15,XXXX

*Age:56years

*Gender:Male

*Race/Ethnicity:Caucasian

*MaritalStatus:Married

*Address:123MainStreet,Anytown,ST12345

*ContactPhoneNumber:(555)123-XXXX

*EmergencyContact:JaneSmith,Wife,(555)456-XXXX

*DateofAdmission/Encounter:October05,YYYY

*AdmittingService/Clinic:InternalMedicine

*AttendingPhysician:Dr.EmilyJohnson

简洁明了地记录患者就诊的主要原因及其持续时间。

Content:

*Aconcisestatementoftheprimaryreasonforthepatientsvisit/admission,inthepatientsownwordsifpossible,followedbytheduration.

Example:

*Chestpainforthepast2hours.

*Worseningshortnessofbreathover3days.

*Follow-upappointmentforhypertensionmanagement.

三、HistoryofPresentIllness(现病史-HPI)

详细描述主诉的发生、发展、演变过程，以及伴随症状、诊治经过等。通常按照时间顺序或逻辑顺序组织。可采用OLDCARTS等mnemonics辅助采集和记录。

OLDCARTSElements(forreferenceinhistorytaking):

*Onset:Whendidthesymptomstart?(sudden/gradual)

*Location:Whereisthesymptom?(specificsite/radiat