1、抗生素医嘱[Antibiotic order] •Prophylaxis [预防性用药] Duration of order[用药时间] 24hr Procedure[操作，手术] •Empiric therapy [经验性治疗] Suspected site and organism[怀疑感染的部位和致病菌] 72hr Cultures ordered[是否做培养] •Documented infection[明确感染] Site and organism[部位和致病菌] 5days •Other[其它] Explanation required [解释理由] 24hr •Antibiotic allergies[何种抗生素过敏] No known allergy [无已知的过敏] •Drug+ dose+ Route+ frequency[药名+剂量+途径+次数]

2、医嘱首页[Admission / transfer] •Admit / transfer to [收入或转入] •Resident [住院医师] Attending[主治医师] •Condition [病情] •Diagnosis[诊断] •Diet [饮食] •Activity [活动] •Vital signs[测生命体征] •I / O [记进出量] •Allergies[过敏]

3、住院病历[case history] •Identification [病人一般情况] Name[性名] Sex[性别] Age [年龄] Marriage[婚姻] Person to notify and phone No.[联系人及电话] Race[民族] I.D. No.[身份证] Admission date[入院日期] Source of history[病史提供者] Reliability of history[可靠程度] Medical record No[病历号] Business phone No.[工作单位电话] Home address and phone No.[家庭住地及电话] •Chief complaint[主诉] •History of present illness[现病史] •Past History[过去史] Surgical[外科] Medical[内科] Medications[用药] Allergies[过敏史] Social History[社会史] Habits[个人习惯] Smoking[吸烟] Family History[家族史] Ob/Gyn History[ 婚姻/生育史] Alcohol use[喝酒] •Review of Aystems[系统回顾] General[概况] Eyes, Ears, Nose and throat[五官] Pulmonary[呼吸] Cardiovascular[心血管] GI[消化] GU[生殖、泌尿系统] Musculoskeletal[肌肉骨骼] Neurology[神经系统] Endocrinology[内分泌系统] Lymphatic/Hematologic[淋巴系统/血液系统] •Physical Exam[体检] Vital Signs[生命体征] P[脉博] Bp[血压] R[呼吸] T[温度] Height[身高] Weight[体重] General[概况] HEENT[五官] Neck[颈部] Back/Chest[背部/胸部] Breast[乳房] Heart[心脏] Heart rate[心率] Heart rhythm[心律] Heart Border[心界] Murmur[杂音] Abdomen[腹部] Liver[肝] Spleen[脾] Rectal[直肠] Genitalia[生殖系统] Extremities[四肢] Neurology[神经系统] cranial nerves[颅神经] sensation[感觉] Motor[运动] *Special P.E. on diseased organ system[专科情况] *Radiographic Findings[放射] *Laboratory Findings[化验] *Assessment[初步诊断与诊断依据] *Summary[病史小结] *Treatment Plan[治疗计划]

4、输血申请单[Blood bank requisition form] (1)reason for infusion[输血原因] ▲红细胞[packed red cells, wshed RBCs]: *Hb *>20% blood volume lost [>20%血容量丢失] *cardio-pulmonary bypass with anticipated Hb *chemotherapy or surgery with Hb ▲全血[whole blood]: massive on-going blood loss[大量出血] ▲血小板[platelets]: *massive blood transfusion >10 units[输血10单位以上者] *platelet count *Cardio-pulmonary bypass uith pl *Platelet count ▲新鲜冰冻血浆[fresh frozen plasma]: *documented abnormal PT or PTT with bleeding or Surgery[PT、PTT异常的出血或手术病人] *specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手术者] *blood transfusion >15units[输血>15个单位] *warfarin or antifibrinolytic therapy with bleeding[华法令或溶栓治疗后出血] *DIC[血管内弥漫性凝血] *Antithrombin III dficiency[凝血酶III 缺乏]

(2)输血要求[request for blood components] *patient blood group[血型] *Has the patient had transfusion or pregnancy in the past 3 months? [近3个月，病人是否输过血或怀孕过？] *Type and crossmatch [血型和血交叉] *Units or ml[单位或毫升]

5、出院小结[discharge summary] Patient Name[病人姓名] Medical Record No.[病历号] Attending Physician[主治医生] Date of Admission[入院日期] Date of Discharge[出院日期] Principal Diagnosis[主要诊断] Secondary Diagnosis[次要诊断] Complications[并发症] Operation[手术名称] Reason for Admission[入院理由] Physical Findings[阳性体征] Lab/X-ray Findings[化验及放射报告] Hospital Course[住院诊治经过] Condition[出院状况] Disposition[出院去向] Medications[出院用药] Prognosis[预后] Special Instruction to the Patient(diet, physical activity)[出院指导（饮食，活动量）] Follow-up Care[随随访]

6、住院/出院病历首页[Admission/discharge record] •Patient name[病人姓名] •race[种族] •address[地址] •religion[宗教] •medical service[科别] •admit (discharge) date[入院（出院）日期] •Length of stay [住院天数] •guarantor name [担保人姓名] •next of kin or person to notify[需通知的亲属姓名] •relation to patient[与病人关系] •previous admit date[上次住院日期] •admitting physician [入院医生] •attending physician [主治医生] •admitting diagnosis[入院诊断] •final (principal) diagnosis[最终（主要）诊断] •secondary diagnosis[次要诊断] •adverse reactions (complications)[副作用（合并症）] •incision type[切口类型] •healing course[愈合等级] •operative (non-operative) procedures[手术（非手术）操作] •nosocomial infection[院内感染] •consultants [会诊] •Critical-No. of times[抢救次数] •recovered-No. of times[成功次数] •Diagnosis qualitative analysis[诊断质量] OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率] Clinical and pathological Dx concur[临床与病理诊断符合率] Pre- and post-operative Dx concur [术前术后诊断符合率] •Dx determined with in 24 hours (3 days) after admission[入院后24小时（3 天）内确诊] •Discharge status[出院状况] recovered[治愈] improved[好转] not improved[未愈] died [死亡] •Dispositon[去向] home[家] against medical ad[自动出院] autosy[尸检] transferred to[转院到]