投影片1TaichungVeteransGeneralHospital臺中1台中荣民总hospital臺中投影片.ppt

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1、投影片1TaichungVeteransGeneralHospital臺中1台中荣民总hospital臺中投影片 Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望2優良的書寫技巧就是要簡、明、達意，用最精簡的方式、文字，完整地描寫現象、過程，正確地表達意見。病書寫，要一眼就能看得清楚！因為病內容複雜，要注意每天的記內容要能夠寫出要點，要讓讀者自己東翻西翻找相關的數據。3病歷英文要正確、文理通順英文還是中文？全世界科學、醫學的新進展差多都用英文發表！是中文、英文，文還

2、是要正確通順。英文一定要用完整的句子，只要意思表達清楚，電報式子句也可。英文佳，反對先用中文補註清楚。以後再學習。4住院病歷記錄主要內容住院病歷記錄主要內容1.Orders2.T.P.R.Sheet3.Admission Note4.Progress Note5.Consultation Note6.Invasive Procedure Record7.Operation Note8.麻醉記錄9.Informed Consent(同意書)10.給藥記錄11.護理記錄12.Discharge Summary13.X光及其他醫學影像報告5Admission Orders 住院醫囑單1.Diagno

3、sis1.Perforated peptic ulcer with sepsis2.Uncontrolled DM3.Old CVA with right hemiplegia4.Hypertension2.AllergyShrimps(urticaria);penicillin(positive skin test或urticaria或probable anaphylactic shock)3.ConditionCritical or guarded或其他應該讓護理人員瞭解的疾病程度4.Diet5.Activity6.Medications最好用學名最好用學名，並註明劑量，儘量不要寫幾顆或幾

4、瓶7.IV fluids誰下的、何時寫的要可以看出來6Discharge Orders醫囑寫法Discharge this afternoonDischarge tomorrow morningDischarge against medical advice(簡寫為discharge AMA，最好不要寫AAD)不宜寫may be discharge(MBD)！出院指示出院處方必須寫藥的學名、劑量、服用方法、供應天數。後續安排OPD F/U in 3 days;Referred back to Dr.Lins clinic7TPR sheet 可以記載日期、TPR、血壓、身高、體重、I/O、BM

5、，drainage之；主要的治藥物、抗生素及其劑；會影響TPR的藥物：退燒藥、類固醇、NSAID、抗生素、輸血、放射線治、化；重要的檢查或處：手術、片檢查、插管拔管、鏡檢、細菌培養、外送檢驗、其他可能常會問到、提到的，和病況進展有關事項；重要的檢查結果、需要常常追蹤的數據：WBC、CRP、培養結果、等等；突發事件：跌倒、昏迷、seizure、等等；（目的就是要使醫護人員或其他人員，對住院後的病程，只看TPR sheet就可以一目瞭然。）8Admission Note1.Chief Complaints2.Present Illness3.Past History4.Personal,socia

6、l and occupational history5.Family History6.Review of Systems7.Physical Examination8.Image and Laboratory9.Impression10.Plan of management and treatment9Admission Note Chief Complaints用病人自己的話描述發病時間要只寫出日期、月份或星期 Abdominal pain since last Sunday.精簡，適當的形容詞Progressive abdominal distention 4 days before(或

7、prior to)admission.Intermittent abdominal pain for 4 hours.Sudden onset of sharp epigastric pain for 2 hours.Tarry stool over the past two days.能只寫 for operation,for chemotherapy，要加上為什麼要做上述治！e.g.Colon cancer diagnosed 2 weeks ago.10Admission Note Present Illness記原則：按症狀出現的先後順序記時間最好少用日期要只寫LMD或local ho

8、spital慢性病必需記使用藥物的名稱和劑、病人服藥情形和反應。11Writing“Present Illness”1.開場白-選擇基本資料中之關鍵詞，融合過去相關病史及主訴作為開場白，如此可將病的全貌摘要地呈現出，有助於列舉出各個問題，並開啟解決問題的步驟。：This 65 year-old man,who is a construction worker with a history of appendectomy,was admitted from our ER because of intermittent abdominal pain for 2 days.SKH122.接著，有系統

9、地記載有助於診斷及治的資料(包括症狀、過去的檢查、治與治的反應等)推敲問題。一些與主訴相關的negative symptoms或history也應寫出，對鑑別診斷相當重要。3.住院的由或適應症也應在最後簡要地陳述。SKHWriting“Present Illness”13Admission Note Present Illness【例】The 50 y/o male patient is a case of hypertension,DM and old CVA for 10 years with regular medications.不要稱病人為male or female man or

10、woman,boy or girl.避免稱病人為“a case”The patient has had hypertension“regular medications”taking medicine as ordered14Present illness 的寫法完整電報式子句High fever up to 39C,sudden onset,daily spike for 4 days;rigor(+)initially;slight dizziness(+);poor appetite(+);severe malaise(+)。Visited Dr.Chens clinic(Address

11、:,Tel#:)daily for 3 days,IV injection daily and two kinds of t.i.d.tablets;no improvement。查問症狀初發時正在做什麼，可以刺激病人的回憶。Muscle ache(+),generalized,severe;mod.bitemporal headache(+).Dry cough,dyspnea,since this morning;rapidly progressive.Came to ER。Needed oxygen right away。No urinary or respiratory symptom

12、s.Loose stool x 2;nausea(+)15Admission Note Past History一般以發生時間的先後決定記載的次序。手術史:手術之時間、當時的診斷、有無器官除、有無輸血、住院多久、追蹤多久。藥物史需特別著重過去對藥品的過敏反應，包括多久以前發生，藥物名稱、發生時的症狀及其處辦法。16Admission Note Personal,social and occupational history生產史、發展史、教育程、職業現況(職業與職稱)、婚姻狀況嗜好、習慣、飲食睡眠情況有無抽煙(及期間)、喝酒(及種類)、咖啡、檳榔、藥物月經、懷孕、生育史17Admission

13、Note Family History遺傳或接觸性疾病：過敏、癌症、感染性疾病、精神疾病、糖尿病、高血壓、心臟病、腎臟病、癲癇、痛風、中風等包括至少三代族譜的繪畫18History taking 要詳細精確！19Admission Note Review of System是為怕遺漏掉一些訊息，應再回顧檢查各器官系統問題、症狀及疾病。有問題者還要詳細問，並放入Past History或Present Illness中。20Admission Note Physical Examination寫出異常的敘述異常的敘述，而是用診斷的名稱。如：結膜是蒼白的，可能是貧血，但要就寫anemic，寫pal

14、e就好！鞏膜是黃的，要寫jaundice，要寫icteric。長度長度及大小大小最好使用公分公分記，避免用egg-sized,palm-sized等！以圖表示更好，但要精確！21Admission Note Impression診斷應儘完整，少用簡寫少用簡寫，除病名外最好加上程度程度。Cirrhosis,alcoholic,Child class C;Spleen laceration,Grade I,hemodynamic stable;Old CVA,with right hemiplegia小心用R/O，要沒有其他診斷就直接寫rule out XXX.Fever,suspected of

15、 UTI,R/O drug fever.如果診斷暫時無法確定，可以寫fever或chest pain,cause to be determinedImpression之後宜有Differential Diagnosis.22Admission Note Plan依處置之優先順序順列順序順列，列出預計檢查與治的計劃，包括照會、用藥等。要只寫：To give iv fluids.To give antibioticsTo give antihypertensives藥名最好用學名學名、寫明劑、給藥途徑及頻率。23Progress Note 的寫法一般以Problem-Oriented Medica

16、l Record(POMR)的方式書寫，最常採用Subjective-Objective-Assessment-Plan(S.O.A.P.)模式，針對每一個active problem逐項(或擇要)寫出SOAP，特別注意病情的變化、評估及處方式。應每天書寫，內容能一成變，切忌張貼同樣字句！無用的數據不必每天打（貼）！主治醫師應counter-sign(複簽)，並加以修改或評語與追加。何種方式，其內容：v一定要記載已接受的治、病情的進展及對醫效果的評估。24SOAP 記錄方式記錄方式S(subjective):symptoms(chief complaints)O(objective):sign

17、s(physical exam)&lab resultsA(assessment):impression/diagnosis and patient or disease conditionP(plan):approaches to diagnosis(lab tests)approaches to therapy(medications,procedures,operation,etc.)approaches to healthcare education SKH25Problem-oriented Progress note 之內容按照住院時列舉之 Impression，逐項討。給什麼治？

18、有沒有好轉（數據）？為什麼？以後如何處？先寫有關此診斷之症狀，如肺炎則描寫咳嗽、痰、胸痛、肌肉痛、頭痛、等等。再記載有關此診斷之檢驗數據，說明和前一次是否較高、較低、或差多。提醒今天是用什麼治的第幾天。寫第幾天，就常會使用過久。說明此問題在你的判斷，今天是否比昨天、前天、或住院時，較好、較壞、或差多。分析你認為是為什麼？最後說明為解決目前的問題，或潛在的問題，要再作何檢查或治。26：#1Chest painS:_O:_A:_P:_#2Upper GI bleedingS.O.A.P.#3ArrhythmiaS.O.A.P.SKH1.2009.08.25 5:00 PM2.#Swelling o

19、f the right side cheek 3 days after 3.surgery.4.S:Swelling of the right cheek.5.O:1.Intraoral exam revealed erosive and swelling of the 6.surgical site of 48 region.7.2.There was no evidence of bleeding,nor exudation.8.3.Panoramic radiograph showed no retained root 9.fragment of 48.10.A:1.Dentigerou

20、s cyst,LR s/p cyst enucleation for 3 days11.2.48 impaction s/p odontectomy for 3 days12.3.Edema over right cheek,more severe than yesterday13.P:1.OHI.14.2.Hot compression,20 min/hr.2728Assessment 錯誤的寫法只重複寫出住院時之impression而沒有評估1.Sepsis,R/O pneumonia2.DM type 23.Cervical CA,S/P total hysterectomy4.Diar

21、rhea29Assessment/Plan 的寫法(一)給什麼治？有沒有好轉？為什麼？以後如何處？(隨期間而會逐漸改善的治療，如抗生素、手術後、及其他大部分處理，應該寫今天是第幾天的治療)1.Sepsis,R/O pneumonia:3rd day of cefuroxime 1.5 gm.q8h.Clearly improving.To continue the same Rx.for 6-7 days.2.DM type 2:Sugar level is under control with.3.History of cervical CA S/P total hysterectomy:C

22、hecked by Gyn.No signs of recurrence.4.Diarrhea has stopped 3 days after admission.Stool culture(-),cause unknown;related to the pneumonia?30Assessment/Plan 的寫法(二)給什麼治？有沒有好轉？為什麼？以後如何處？1.High fever:Received 5 days of empiric clarithromycin 500 mg,bid.Does not seem to be improving.May be viral infecti

23、on.Will D/C the antibiotic and observe.To check the report of influenza,parainfluenza virus antibodies.Renal function is worsening,will check for Hantavirus and Leptospira antibodies.No jaundice.2.Vomited twice yesterday.2 hours after lunch.No diarrhea.No meningeal signs.Cause not clear.To continue

24、observation.31Weekly SummaryWeekend summary幫助值班醫師瞭解病情。內容應該含：病人何時住院住院的主要問題是什麼過去一週做什麼處置病情及治反應如何下週的計畫是什麼是將住院記COPY過！32Consultation Note有照會時除寫會診單外，應該在病程記中寫照會那一科的醫師，並把照會醫師的回覆意見簡要的寫在病裡。寫會診單時應多寫有關病人的病史及檢驗數據，下列的客套話可免寫：We sincerely requestYour nationally reputabel expertise,33Invasive Procedure Record所有侵入性的檢查

25、和處置都應以紅筆記，包括：各種內視鏡檢查、血管攝影、組織片、各種體液抽取、導管放置、氣管插管等記內容：執時間、地點執的原因、方法、麻醉方式檢查時的發現、處置方法、有無併發症執者及協助者姓名34Discharge Summary 應注意事項應注意事項(1)1.出院診斷Primary(主要診斷)引起病人此次住院的主要病況Secondary(次要診斷)原已存在或者後才發展的病況，且影響醫/住院天數者。*與此次住院醫療無關的疾病不應包括在內與此次住院醫療無關的疾病不應包括在內:主要診斷：1)acute congestive heart failure2)acute myocarditis 次要診斷：1

26、)aspiration pneumonia2)ventricular tachycardia SKH35Discharge Summary 應注意事項應注意事項(2)2.Brief history：要重覆冗長的住院記中所寫的present illness，應簡單地描述病人住院之由及相關的現在病史。3.Hospital course：應扼要地依時程描述(要用列表方式)病人住院期間所作過的主要檢查與治經過。4.檢驗結果(Lab results)：應列出所有的血液及生化報告，應將他們消化後，寫出與病況有關的positive與pertinent negative findings。SKH36Disch

27、arge Summary 應注意事項應注意事項(3)5.Discharge medications：應以獨立heading列出所有出院用藥，藥物名稱須用generic name；要寫出劑(100 mg，寫one tablet)與用法。6.Follow-up plan(追蹤計劃)。7.Instructions to the patient(給病人的指示)：這點在國內做得最夠，常被忽略。衛生署的病書寫範也沒特別強調，只是列舉“出院後之建議及用藥”(Recommendations and medications)。8.應寫出referring physician或primary care physi

28、cian 的名字，並且寄一份出院摘要的影印本給他們。SKH醫法（IDP）寫作格式）寫作格式記載醫學與法的討。其病記方式使用 IDP（Issue,Discussion,Planning）三段述的方式）三段述的方式37醫法（IDP）寫作格式）寫作格式 Issue：關於該個案之醫學與法的爭議點。床上可能面的爭議點如下：病患自主權、告知同意、病患的決定能、病患的自願、代決定、告知病患實情、守密、兒童的醫決定、研究、安死、終生命照護、自動出院、孕婦與胎兒衝突、資源分配、基因檢測與遺傳的爭議等。38醫法（IDP）寫作格式）寫作格式 Discussion：針對該特定個案，對爭議點進討。(1).討的方式可以用

29、對談的型態，將討的重點加以整，以專業的知診斷，將情況用淺顯懂的話語告知家屬及病患，解答病患及家屬心中的疑問。如：醫護人員與病患之對談、醫護人員與病患家屬之對談、主治醫師與住院醫師對談。39醫法（IDP）寫作格式）寫作格式 Discussion：針對該特定個案，對爭議點進討。(2).也可以由同的角出發，思考該爭議點，如：以病患的自主權出發、考慮病患的最佳、考慮社會經濟的整體等。40醫法（IDP）寫作格式）寫作格式 Discussion：針對該特定個案，對爭議點進討。(3).告知內容須把握五項原則：甲、診斷結果 乙、治的方式與過程 丙、可能產生的合併症 丁、預後情況 戊、是否有其他治方式的選擇41

30、醫法（IDP）寫作格式）寫作格式Planning：在經過討後，針對該議題決定如何處。42醫法（IDP）寫作格式）寫作格式Issue：請家屬代決定作氣管管事宜。Discussion：主治醫師：由於病患的父親已中風，意清，且痰液無法自咳，故必須接受氣20手術，以於日後照顧。家屬 A：我們願意做氣手術，願意讓父親再接受任何的痛苦。主治醫師：接受氣手術，可能就要一直有氣管內管維持呼吸道通暢，而氣管內管會有堵的危險，且換氣管內管時相當危險。家屬 A：我再和我母親商好。Plan：安排下次與病患之配偶與兒子晤談。43以英文記載病常見的錯誤45性別、所有格的錯誤【例】：Patient is a 62 year

31、s old female,his chief complaint is abdominal pain.建議：The Patient is a 62 years old woman,her chief complaint is abdominal pain.有關主訴（chief complaint）的寫法：1.The patient is a 62-year-old woman,and her chief complaint is abdominal pain.2.A 12-year-old girl complained of abdominal pain.3.A 7-year-old boy

32、 was admitted to the hospital because of abdominal pain.4.A 40-year-old man presented with abdominal pain.*Do not just use male or female;write“man”or“woman”.46時態(tense)的錯誤【例】：He had hypertension and still on three kinds of antihypertensive.建議：1.He has hypertension and still on three kinds of antihy

33、pertensives.2.He has hypertension and is on three kinds of antihypertensives.3.He has hypertension and is on three kinds of antihypertensive medications.【例】：Before he came to our clinic today,he had ever went to another two hospital clinics.建議：Before he came to our clinic today,the patient had visit

34、ed clinics at two other hospitals.建議：Before he came to our clinic today,the patient had been to clinics at two other hospitals.47介系詞的錯誤【例】：In last Saturday,his headache was suddenly got worse.建議：Last Saturday,his headache suddenly got worse.【例】：The patient had an acute process superimposed to his ba

35、ckground conditions.建議：The patient had an acute process superimposed on his background conditions.【例】:A 45 year-old woman of mitral stenosis.建議:A 45 year-old woman with mitral stenosis.48主詞的錯誤【例】：Cancer was told這是主詞弄亂了。建議：1.The patient was informed to have cancer.2.The patient was told to be having

36、cancer.3.He was diagnosed to have cancer.4.He was told to have cancer.49單字、單詞的錯誤【例】：Acception note 建議：沒有acception一字，應該是 acceptance note 或 on service note(相對的可寫off service note)【例】：Progression note；Progressive note.建議：應寫成 Progress note。【例】:Past history:Nil.建議:Nil is a Latin word;it means“nothing”or“Z

37、ero”.應寫成“Non-contributory”.50單字、單詞的錯誤(續)【例】：Discharge diagnosis:R/O cancer.建議:R/O(rule out)是“須排除”、“應排除”之意，R/O cancer 可用於住院時的診斷。不過住院診斷工作(work up)之後，癌症的診斷應該是已經被ruled in 或ruled out。如診斷仍未被確認，而癌症還是最有可能，則應寫成Discharge diagnosis:probable cancer或suspected cancer。【例】：sepsis、septicemia、bacteremia的用法。建議：有感染症狀時稱

38、為sepsis(敗毒症)，再加上血液培養有細菌，則稱為septicemia(敗血症)。只血液培養有細菌則稱為bacteremia(菌血症)。醫用英文翻譯成中文時，應該注意其原有的希臘文或拉丁文的字根意義。51錯誤使用 positive 或 negative【例】：The biopsy was negative.The exercise testwas positive.The ECG was negative.檢驗結果要用“positive”或“negative”這些應該寫為：Laboratory tests(studies)gave normal results.Laboratory tes

39、ts showed normal values.Laboratory data were normal(or within normal limits).The result of the biopsy was unremarkable.The exercise test was abnormal.The ECG revealed no abnormality.52Nothing particular(N.P)或non-made的誤用在病歷書寫時應避免寫“無特殊之處”，應該寫出詢問出什麼，結果正常、或無發現；或是做了檢查，結果正常。故英文應用negative for,unremarkable,

40、non-contributory等字詞。【例】：The family history was nothing particular.應 改 為：The family history was unremarkable(or non-contributory).Non-made是說做了切片檢查，沒有發現不正常的（癌）細胞。但是，英文不這麼說。【例】：The biopsy was non-made.The pathology was non-made.應改為：The pathology did not reveal malignant cells.或是No malignant cells were

41、found in the biopsy specimen.53贅語或俗語常使用兩個名詞連在一起，或是為節省書寫將一些簡寫當作名詞或動詞。肝硬化應該是cirrhosis，而常寫成liver cirrhosis或是cirrhosis of the liver.Cirrhosis本身就是肝硬化，因此不須加上liver。seizure attack,只需寫seizure，或epileptic fit。a tumor mass，應寫為 a tumor,a mass(lesion)。fever of 38C應寫為(fever with)a temperature of 38C。The patient wa

42、s AAD(against advice discharge,自動出院)，應寫為The patient was discharged AMA(against medical advice)或 to be discharged AMA 或 discharge AMA。The patient MBD(may be discharged)today.意思是“可以出院”，應寫為The patient is ready for discharge today.或to be discharged；discharge today；discharge tomorrow morning 或 discharge

43、in AM。54其他常見的不當使用語詞VictimVictim翻譯是“受害者”，病人雖然受病痛，但是使用這個字不當。何況已經寫patient，不須再用victim。【例】：The patient is a victim of type 1 DM diagnosed since 2 years ago.應 寫 為：The patient was diagnosed as having type 1 DM two years ago.【例】:The patient is a victim of motor vehicle accident(MVA).應寫為:The patient had a MV

44、A.55其他常見的不當使用語詞Unfortunately常見病歷寫Unfortunately,the patient had.，這個意思是說病人的情況本來是穩定的，但是後來發生了某些症狀或是事件。病人生病本來就是不幸的事，不須再強調，不須以哀傷的語氣如unfortunately、sadly、miserably、unluckily等呈現在病歷。【例】：Unfortunately,nausea,vomiting and abdominal pain developed since last night,and the patient was brought to ER for help.應改為：T

45、he patient was well until last night when nausea,vomiting and abdominal pain developed,and he was brought to the ER.56其他常見的不當使用語詞A test(or examination)was arranged(performed),which showed不須寫安排或者執行什麼檢查，直接寫出檢查發現什麼即可。【例】：CT scan of the head was arranged(performed),which showed subdural hematoma over th

46、e left parietal area.應改為：A CT scan of the head showed subdural hematoma over the left parietal area.57其他常見的不當使用語詞Culture showed bacteria細菌培養長出細菌不適用show或reveal，應該用yield 或 grow【例】：The sputum culture showed Streptococcus pneumoniae infection.應改為：The sputum culture yielded(grew)Sreptococcus pneumoniae.B

47、acterial culture was positive for Streptococcus pneumoniae.58其他常見的不當使用語詞According to the statement of the patient這似乎強調這份病歷是病人親口說的，其實病歷不是司法的筆錄，只要說是根據病人或誰陳述即可，或是直接說病人如何。應改為：According to the patient,.或 The patient stated that she had epigastric discomfort 30 minutes after last dinner.According to the p

48、atients mother,59其他常見的不當使用語詞During the period of admission這是中式英語的另一例子，亦即“住院期間”。但是admission是由醫院進入病房的一個行為，因此沒有所謂period。應該寫為During the hospitalization或是During the hospital stay。60其他常見的不當使用語詞A disease was diagnosed.The patient was diagnosed as a disease.中文的意思是很簡單，“病人診斷什麼病”，但是英文不能寫為“疾病被診斷”；也不能寫為 “病人被診斷成（

49、as a disease）什麼病”。【例】：Colon cancer was diagnosed.應改為：The patient was diagnosed as having colon cancer.或是 A diagnosis of colon cancer was made.61其他常見的不當使用語詞使用太多連接詞，使句子太長使用太多連接詞，使句子太長 The patient went to the hospital and was diagnosed of osteoarthritis,so medications were given and the pain decreased

50、in severity,but she had to take the medicines regularly.應改為：The patient went to the hospital,where a diagnosis of osteoarthritis was made.She took analgesics regularly with some relief of her pain.62其他常見的不當使用語詞Irregular control,Regular medication常看到病歷寫irregular control或irregular medication或regular m