2011/6/3 YU HONGYAN English medical records w riting 1 / 13 【前言】： 病历的书写，不管情不情愿，是我们见习、实习生活中十分重要的一部分。中文病历是基本要求，英文病历是附加题。对于书写英文病历，首先要明确自己的目的和期望。比如说通过书写英文病例学习专业词汇，与国际接轨；将来考虑出国；好奇心使然等等。有此意愿的同学大可好好思考一下，给自己一个理由和动力。 协和有写英文病历的传统，但还没有统一、固定的格式。不过格式不外乎：国外原版和中文病例对译版。目前黄老师坚持，如果我们要写英文病历，就要跟国际化的要求接轨，所以支持原格式和写作习惯。 但具体格式，都因医院、因人而异。故总结中注重的是—提出基本框架，规范术语。大家可作适合自己的微调。 A COMPLETE History & Physical HISTORY Date and Time of history: Identifying Data： Source of history, source of referral: Reliability: Chief complaints: quote the patient’s complaints, like “My stomach hurts and I feel awful”; or report their goals, like “I have come for my regular check-up”;[BATES’] patient’s age, a brief but relevant past medical history, a few words about what problem brings the patient to the hospital(preferable quote the patient), and duration[Writing a history & physical] e.g. 34-year-old male with advanced AIDS complains of a” bad cough” and fevers over the last 8days. 56-year-old male with a history of ulcerative colitis complains of 3 months of worsening back stiffness, 2 weeks of “a sore on my leg”, and 3days of fevers and bloody, painless diarrhea. History of Present illness: full sentences in chronological manner be descriptive not analytic including the setting, onset of the problem, the manifestation and the treatment. Seven Attributes of A Symptom: location, quality, quantity or severity, timing(onset, duration, frequency), the setting in which they occur, factors that have aggravated or re...
