病歷文書中常用基本用語的英文翻譯,快快收藏哦！
1、抗生素醫囑[Antibioticorder]
?Prophylaxis[預防性用藥]
Durationoforder[用藥時間]24hr
Procedure[操作，手術]
?Empirictherapy[經驗性治療]
Suspectedsiteandorganism[懷疑感染的部位和致病菌]72hr
Culturesordered[是否做培養]
?Documentedinfection[明確感染]
Siteandorganism[部位和致病菌]5days
?Other[其它]
Explanationrequired[解釋理由]24hr
?Antibioticallergies[何種抗生素過敏]
Noknownallergy[無已知的過敏]
?Drug+dose+Route+frequency[藥名+劑量+途徑+次數]
?Admit/transferto[收入或轉入]
?Resident[住院醫師]Atting[主治醫師]
?Condition[病情]
?Diagnosis[診斷]
?Diet[飲食]
?Activity[活動]
?Vitalsigns[測生命體征]
?I/O[記進出量]
?Allergies[過敏]
3、住院病歷[casehistory]
?Identification[病人一般情況]
Name[性名]
Sex[性別]
Age[年齡]
Marriage[婚姻]
PersontonotifyandphoneNo.[聯系人及電話]
Race[民族]
[身份證]
Admissiondate[入院日期]
Sourceofhistory[病史提供者]
Reliabilityofhistory[可靠程度]
MedicalrecordNo[病歷號]
BusinessphoneNo.[工作單位電話]
HomeaddressandphoneNo.[家庭住地及電話]
?Chiefcomplaint[主訴]
?Historyofpresentillness[現病史]
?PastHistory[過去史]
Surgical[外科]
Medical[內科]
Medications[用藥]
Allergies[過敏史]
SocialHistory[社會史]
Habits[個人習慣]
Smoking[吸煙]
FamilyHistory[家族史]
Ob/GynHistory[婚姻/生育史]
Alcoholuse[喝酒]
?ReviewofAystems[系統回顧]
General[概況]
Eyes,Ears,Noseandthroat[五官]
Pulmonary[呼吸]
Cardiovascular[心血管]
GI[消化]
GU[生殖、泌尿系統]
Musculoskeletal[肌肉骨骼]
Neurology[神經系統]
ocrinology[內分泌系統]
Lymphatic/Hematologic[淋巴系統/血液系統]
?PhysicalExam[體檢]
VitalSigns[生命體征]?
P[脈博]
Bp[血壓]
R[呼吸]
T[溫度]
Height[身高]
Weight[體重]
General[概況]?
HEENT[五官]
Neck[頸部]
Back/Chest[背部/胸部]
Breast[乳房]
Heart[心臟]?
Heartrate[心率]
Heartrhythm[心律]
HeartBorder[心界]
Murmur[雜音]
Abdomen[腹部]?
Liver[肝]
Spleen[脾]
Rectal[直腸]
Genitalia[生殖系統]?
Extremities[四肢]?
Neurology[神經系統]
cranialnerves[顱神經]
sensation[感覺]
Motor[運動]
*[?？魄闆r]
*RadiographicFindings[放射]
*LaboratoryFindings[化驗]
*Assessment[初步診斷與診斷依據]
*Summary[病史小結]
*TreatmentPlan[治療計劃]
4、輸血申請單[Bloodbankrequisitionform]
(1)reasonforinfusion[輸血原因]
▲紅細胞[packedredcells,wshedRBCs]:
*[血色素8.5]
*20%bloodvolumelost[20%血容量丟失]
*cardio-pulmonarybypasswithanticipatedHb8[心肺分流術伴預計血色素8]
*chemotherapyorsurgerywithHb10[血色素10的化療或手術者]
▲全血[wholeblood]:
massiveon-goingbloodloss[大量出血]
▲血小板[platelets]:
*massivebloodtransfusion10units[輸血10單位以上者]
*plateletcount50×103/μlwithactivebleedingorsurgery[血小板5萬伴活動性出血或手術者]
*Cardio-pulmonarybypassuithpl100×103/μlwithoctivebleeding[心肺分流術伴血小板10萬，活動性出血者]
*Plateletcount20×103/μl[血板2萬]
▲新鮮冰凍血漿[freshfrozenplasma]:
*documentedabnormalPTorPTTwithbleedingorSurgery[PT、PTT異常的出血或手術病人]
*specificclottingfactordeficiencieswithbleeding/surgerg[特殊凝血因子缺乏的出血/手術者]
*bloodtransfusion15units[輸血15個單位]
*warfarinorantifibrinolytictherapywithbleeding[華法令或溶栓治療后出血]
*DIC[血管內彌漫性凝血]
*AntithrombinIIIdficiency[凝血酶III缺乏]
(2)輸血要求[requestforbloodcomponents]
*patientbloodgroup[血型]
*Hasthepatienthadtransfusionorpregnancyinthepast3months?[近3個月，病人是否輸過血或懷孕過？]
*Typeandcrossmatch[血型和血交叉]
*Unitsorml[單位或毫升]
5、出院小結[dischargesummary]
PatientName[病人姓名]?
MedicalRecordNo.[病歷號]?
AttingPhysician[主治醫生]?
DateofAdmission[入院日期]?
DateofDischarge[出院日期]?
PrincipalDiagnosis[主要診斷]?
SecondaryDiagnosis[次要診斷]?
Complications[并發癥]?
Operation[手術名稱]?
ReasonforAdmission[入院理由]?
PhysicalFindings[陽性體征]?
Lab/X-rayFindings[化驗及放射報告]?
HospitalCourse[住院診治經過]?
Condition[出院狀況]?
Disposition[出院去向]?
Medications[出院用藥]?
Prognosis[預后]?
SpecialInstructiontothePatient(diet,physical?activity)[出院指導（飲食，活動量）]?
Follow-upCare[隨隨訪]?
?Patientname[病人姓名]
?race[種族]
?address[地址]
?religion[宗教]
?medicalservice[科別]
?admit(discharge)date[入院（出院）日期]
?Lengthofstay[住院天數]
?guarantorname[擔保人姓名]
?nextofkinorpersontonotify[需通知的親屬姓名]
?relationtopatient[與病人關系]
?previousadmitdate[上次住院日期]
?admittingphysician[入院醫生]
?attingphysician[主治醫生]
?admittingdiagnosis[入院診斷]
?final(principal)diagnosis[最終（主要）診斷]
?secondarydiagnosis[次要診斷]
?adversereactions(complications)[副作用（合并癥）]
?incisiontype[切口類型]
?healingcourse[愈合等級]
?operative(non-operative)procedures[手術（非手術）操作]
?nosocomialinfection[院內感染]
?consultants[會診]
?[搶救次數]
?[成功次數]
?Diagnosisqualitativeanalysis[診斷質量]
[門診入院與出院診斷符合率]
ClinicalandpathologicalDxconcur[臨床與病理診斷符合率]
Pre-andpost-operativeDxconcur[術前術后診斷符合率]
?Dxdeterminedwithin24hours(3days)afteradmission[入院后24小時（3天）內確診]
?Dischargestatus[出院狀況]
recovered[治愈]
improved[好轉]
notimproved[未愈]
died[死亡]
?Dispositon[去向]
home[家]
againstmedicalad[自動出院]
autosy[尸檢]
transferredto[轉院到]
