6%20入院錄寫作ppt

1、Overview Admission Note,入院錄寫作概述,楊明山,Classification of Medical Writing,Admission Note,Classification of Medical Writing,MIAs abstractIMRAD paperSystematic Review,General Medical Record (History)Admission NoteDaily Re

2、cordDischarge Note,,Admission Note,Clinical Record,POMRProblem-oriented Medical Record,Lawrence Weed. MD.,1947: Columbia University？: Yale University School of Medicine1964: “Medical records, patient care, and medic

3、al education”,,,,,,(Admission Note),Medical Writing Series4.20 method,入院錄廿句寫作法,Chief Complaint,Section One,Chief Complaint,Section OneOnly 1 sentence,第1句 – 主訴 - 寫作分析,第1句 – 介詞妙用 – 主訴,A 25 year-old ladywas admitted to1

4、this hospital on2 May 11, 2003 because of3 fever and cough with4 chill for5 three days.,Histories,Section Two,Histories,Section TwoCurrent History,第2句 – 起病寫作分析,第3句 – 演變寫作分析,第4句 – 經(jīng)治寫作分析,第4句 - 其他表達(dá),home medication cust

5、omary medicationoutpatient medicationsNo treatment,第4句 – 經(jīng)治效果表達(dá),第5句 – 狀態(tài)寫作分析 – 無特殊,現(xiàn)病史寫作關(guān)鍵：time adverbial,點(diǎn)：Since the initial diagnosis, ……. 時(shí)刻：……. at approximately 5 a.m.小時(shí)：Several hours after these symptoms, …..半天

6、：That afternoon ……. 天：On the fifth hospital day …….. 天：On hospital day 5 ……. 周：Over the next week …….月：Two months prior to admission, ……. 年：One year ago …….,Histories,Section Two Other Histories,第6句 – 過去病史寫作分析,F

7、amily, Personal, Ob/Gyn (Childbearing) H.,Customary medications were xx.His only medication was xx for xx.P did not smoke and rarely consumed alcohol.P had a x-pack-year smoking historyThere was a (no) family history

8、 of xx.Parents are alive and well.P died of x at the age of,第7句 – 家族史寫作分析,Examinations,Section Three,第8句 – 生命體征寫作分析,第9句 – 望診寫作分析,第9句 – 望診寫作要求,,部位: Vigorous small intestinal peristalsis can be seen in the center of the

9、abdomen. 時(shí)間: Symmetrical distension is seen when intra-abdominal content is increased.特征: An enlarged uterus was seen as a central rounded suprapubic swelling. 病理: Paralytic ileus is seen in patients after abdominal s

10、urgery.,第10句 – 叩診聽診寫作分析,第10句 – 觸診表達(dá),To be palpated；To be felt,部位：Small masses (nodules) are felt near the uterus or in the cul-de-sac.時(shí)間: No fibroids are felt during the bimanual pelvic or rectal exams.特征: His neurolog

11、ic exam demonstrated mild generalized hypotonia,第10句 – 叩診表達(dá),To be heard；tap, strike, flick, Percuss,部位: These sounds are heard only over the bronchi and trachea. 時(shí)間: Friction was heard in both inspiration and expiration

12、.特征: The cancerous area was felt as a hard, irregular nodule.病理: It is heard in bronchiectatic cavities or pneumothorax.,第10句 – 聽診表達(dá),location： A soft, high-pitched, holosystolic blowing murmur is heard in the mit

13、ral area. time： A murmur can be heard during the diastole.feature His lungs were clear to auscultation. other An aortic murmur is heard with the patient sitting forward in full expiration.,第10句 四診句型-介

14、詞短語,On physical examination, …A tapping apex beat may be apparent on inspection. (最多）Ill-defined nodule margins by palpation The nodule was evident at palpation,第11句 – 輔助檢查寫作分析,Imaging, Ultrasound and Others,Doppler s

15、tudies revealed normal blood flow to both ovaries.A friable lesion 15 to 20 mm in diameter was identified very low in the rectum.During a digital rectal examination, a mobile, soft mass was found low in the left rectum

16、.,⒂ Imaging, Ultrasound and Others,PatternExam showed …The liver was shown to be enlarged…The heart murmur was heard … 檢查項(xiàng)目作主語：主動(dòng)態(tài)陽性體征作主語：被動(dòng)態(tài)人的器官作主語：被動(dòng)態(tài),第12句 – 實(shí)驗(yàn)寫作分析,第12句 – lab 表達(dá) - Same,Item was normal.Item was

17、positiveItem was negativeItem was number,A serologic test for antibody to Helicobacter pylori was positive. The urine was positive for ketones (++).The uterine volume appeared normal.A stool specimen was negative fo

18、r occult blood.,第13句 – 采樣寫作分析,第14句 – 寫作分析 – 回報(bào),Universal There-be 萬能句,Current History: On the sixth day, there was an episode of bradycardia and vomitingPrevious Hisroty: There was no history of sexually trans

19、mitted disease.Inspection There was swelling in one rear “ankle” as well. Palpation There was a large hard irregular mass in the abdomen.Percusion There was a minimal corneal reflex in the left eye.Auscul

20、ation There were scattered rales and rhonchi all over the lung fields.,Approach,Section Four,第15句 – 正文 – 診斷,Our impression of the case would be severe acute respiratory syndrome.,第15句 – 診斷寫作分析,第16句 – 治療寫作分析,第16句 – 治療

21、其他表達(dá),Xx givenXx prescribedXx institutedXx was administered,administered taken orallyinjectedinfused intravenously, intramuscularly, by TPN,第17句 – 寫作分析,第18句 – 當(dāng)前問題寫作分析,第19句 – 寫作分析,第20句 – 寫作分析,診療計(jì)劃,入院: 一般過去 - was g

22、iven至今: 現(xiàn)在完成 - has been given目前: 現(xiàn)在進(jìn)行 - is being given將來: 一般將來 - will be given,Summary,4-section,Personal details （個(gè)人資料）Admission date（入院日期Major complaint（主訴）Present history（現(xiàn)病史）previous & other histories（過去病史

23、等）Physical examination done（體檢）Laboratory done（實(shí)驗(yàn)室檢查）Impression（印象）Problems （問題列單） Initial plan for treatment（初步處理）,病史匯報(bào)廿點(diǎn)寫作法,Four days ago,. A 25 year-old lady was admitted toThe next day she complained of Self

24、 administration ofThe patient was in goodThe patient has beenPhysical examination on admission:Body temperature (was)And she was foundThe right lower posterior chest showed,X-ray films of the chest showed The whit

25、e blood cell count And the blood has been sampledThose lab reports haven’t arrived. Our impression of the case would be On the day of admission,Oxygen and CPAPHowever the patient’s temperature is The patient will

26、be givenAnd meanwhile the patient will be given,The Marriage of Figaro - Overture (1786),The case presentation based on the admission note is the overture of the Medical bilingual education,I wish you would be a new gen