[转]英文病历写作模板

转一份英文病历模板，学习下英文的同时也了解一下国外的病历书写规范

PATIENT HISTORY
病 史

A detailed
patient history and physical exam form the foundation of patient
evaluation and vital patient data that enables efficient, quality
patient rounds.
一份详细的病史和体检是评估患者的基础，也可为组织高质量、高效率的查房提供重要的资料。

On
the other hand, a poorly documented history and physical may leads to
confusion, serious omission of vital data and inefficiency on patient
rounds. In this age of modern technology with equipment such as CT, MRI
and PET scanners, the history and physical exam seem to be slowly
evolving into a relic of a past era! Both attending physicians as well
as residents in training seem to rely more heavily on laboratory and
imaging modalities than history to establish the diagnosis. “However no
part of the patient evaluation is more essential to diagnosis than the
patient history. The importance of skillful data collection is
underscored by the widely accepted understanding that the medical
history contributes 60% to 80% of the information needed for accurate
diagnoses.” Thus to neglect the patient history denies the physician of a
“vital” diagnostic tool.
另一方面，写得差的病史和体检可能会引起混淆，导致重要资料的遗漏和查房
效率的低下。在这个具有现代化设备如CT、MRI、PET的年代里，病史和体格检查似乎已慢慢地成为一种历史遗物。无论是主治医生或住院医生都似乎越来越
依赖于实验室和影像学检查而不是病史来明确诊断。然而对诊断来说，没有一种评估手段比病人的病史更重要。尽管普遍认为病史可提供准确诊断所需的60％一
80％的信息，但有效地收集资料的技能仍被低估了。所以若忽略了患者的病史就意味着剥夺了医生的一种最重要的诊断工具。

The basic outline structure for the patient history and physical exam usually includes the following:
l Identification: patient name, age, gender, race, and occupation
l Chief Complaint: (in the patient’s words)

l HPI: (history of present illness)

l PMHx: (past medical history)

l Medications: should include current meds as well as medication allergies
病史和体格检查的基本框架内容通常包括以下内容：

l 身份证明：患者姓名，年龄，性别，种族和职业

l 主述：(用患者的话表达)

l HPI：现病史

l PMHx：过去史

l 药物史：包括现在使用的药物以及药物过敏史

l ROS: review of systems

l Social Hx.: includes family situation (married, divorced,
single), habits; cigarettes, alcohol or illicit drug use, sexual
behavior

l Physical Exam:

l Impression/Diagnosis:

l Treatment Plan:
l ROS：系统回顾

l 社会史：包括婚姻状态(已婚、离婚、单身)、习惯、吸烟、饮酒或吸毒、冶游史

l 体格检查：

l 诊断：

l 治疗方案：

l Self- introduction: Upon
arrival at the patient's bedside, the physician should first try to
establish rapport with the patient by using “nonverbal cues” such as
maintaining eye contact or extending a hand to shake the patient’s hand
(if “culturally” acceptable). The physician or student should first
introduce him or herself and state their reason for the visit. Also,
they should ask the patient’s permission to interview them.医学.全在线www.***.com
l 自我介绍：到达病人床边时，医生应通过非言语的方式如保持视线的接触或伸手去和病人握手(如果风俗上可以接受)来与病人建立融洽的关系。医生或医学生首先应自我介绍并解释来看病人的原因，并且应在交流前取得病人的同意。

Here are a few specific points about each section of the history outline:

1. Identification -- This should include the patient's name, age,
sex, race and occupation for example: “Mr. Jones is a 55 yr. Old
Caucasian male who works as a farmer.” The patient’s name written in the
history allows future interviewers to address the patient by his name
which conveys a sense of patient respect. The age, race, sex and
occupation are an important as many diseases are not only gender and age
dependent, but may also occur more commonly in specific ethnic and
occupation groups.
以下是病史相关部分的说明：
1.
身份证明--这应该包括病人的姓名、年龄、性别、种族和职业。比如“琼斯先生是一位55岁的白人男性，职业是农民”。在病史中写明患者的姓名有利于以后的
人员用病人的姓名来和他打招呼，这样会使病人产生一种受尊重感。年龄、种族、性别、和职业都非常重要，因为许多疾病不仅与性别和年龄有关，并且在特定的种
族或职业人群中更为常见。

2. Chief complaint -- This should be
written in the patient’s words. For example “chest pain” rather than
“angina”. Also the duration of the chief complaint should be noted
“chest pain for 1 hour”. Before moving on to the HPI, it would be
appropriate to perform a “survey of problems” asking the patient if
there are any other current problems bothering them. Once these have
been listed, the interviewer can come back to the original Chief
Complaint the patient presented with and obtain the details in the HPI.
However “associated” symptoms should be descried in the HPI.
2.

主述--主述应该用病人的语言来写。比如“胸痛”而不是“心绞痛”。而且应同时写明主诉的时间如“胸痛1小时”。在开始采集现病史之前，应补充问病人是否
还有其他不适症状。一旦发现有其他症状应补充到主诉中，并在现病史中详细描述。但伴随症状应在现病史中描述。

3.
HPI (History of Present Illness) --The history of the present illness
is a more elaborate description of the patient’s chief complaint and is
the most important structural element of the medical history. This
section should give the following details about the chief complaint (s):

3. 现病史--“现病史是对病人主诉更为详细的描述，是病史中最为重要的组成部分。”在这部分中应对主诉从以下几个方面加以详细描述。

a. Detailed description of the “chief complaint”; “a dull crushing chest pain” including body location of the complaint.

b. A chronological history and sequence of the chief complaint.
c. What circumstances precipitated it: climbing stairs, emotional upset such as anger, or sexual intercourse.

d. What circumstances relieve it: resting for a few minutes.
a． 对“主诉”更为详细地描述；如“压榨样胸部闷痛”，应包括主诉的部位。

b． 主述的发展变化。

c． 诱因：如爬楼梯、情绪激动，如发怒、性生活等。

d． 缓解因素：如休息几分钟、硝酸甘油。 医学 全在.线提供

4. ROS
(Review of Systems) -- This section is too often omitted. Although it is
somewhat cumbersome to go through a “complete” review of systems and it
may not be necessary to do so for “each” admission, at least one
“complete” review of systems should be documented in the patient's
medical record. For subsequent admissions the history could simply refer
back to the “complete ROS” documented on a specified date. However,
even with subsequent admissions, a minimum would be to include in the
HPI a “pertinent” ROS of the organ - system of Chief complaint.

4. ROS(系统回顾)--很
多情况下这一部分被省略了。尽管对每个系统作一个完整的回顾有些麻烦，并且每次住院都这么做可能不一定必要，但是在病人的病史记录中应至少有一次完整的系
统回顾。此后的住院即可指明参考某年某日这份完整的系统回顾。但是即使在以后的住院病史中，至少应在现病史中对主诉相关的器官系统作——系统回顾。

5.
Social History -- This section is the most neglected section of the
patient history performed in China. Vital information such as smoking
history, use of alcohol or illicit drugs and sexual behavior can give
invaluable clues to the diagnosis. Cigarette smoking is a risk factor
for a vast array of diseases including cancer, coronary heart disease,
COPD and GI diseases. In China, the prevalence of smoking among females
is only about 5%. However, it's gradually increasing among young
females. Thus physicians frequently forget to ask females about their
smoking history. Also documentation of the patient’s marital status
(divorced) and family situation may give clues to the early diagnosis of
anxiety or depression. A brief family medical history should also be
included if not already mentioned in the HPI.
5.
社会史--在中国的大病史中这一部分是最常被忽略的部分。重要的信息如吸烟史、饮酒或吸毒史、性行为对诊断常能提供非常重要的线索。吸烟是很多疾病的危险
因素包括癌症、冠心病、COPD和消化系统疾病。在中国，女性吸烟率仅为5％。但在青年女性中在逐渐升高。而对于女病人来说，医生常常会忘记问吸烟史。同
时写明婚姻状况(离婚)和家庭状况对于早期诊断焦虑或抑郁也有帮助。如果在现病史未提到，则应对家族史做一简单的阐述。

Although
we’ve described a nice, neat “outline” for the patient history, when
the medical student first begins to interview take a history, he quickly
discovers that fitting patient’s responses into a “neat” history and
physical outline is indeed a challenge and requires much patience and
practice! Patients have not been told their responses are to “fit” into a
structured format! When asked a specific question by the medical
student/physician interviewer, they may assume they should give as much
information as possible, thus the interviewer is forced to “sift”
through their response and retain only the pertinent data for the
medical record.
尽管我们对如何采集病史提出了—个清晰明了的框架，但是当医学生们第—次去采集病史时．他们很
快会发现把病人的反应归纳到—个清晰明了的框架中去并不是一件易事。这需要耐心和实践。病人们并不知道他们的回答要被纳入到—个结构化的表格中去!当医学
生或医生问及一个特定的问题时，病人会认为应该提供尽可能多的信息，所以采集病史者不得不从病人的回答中筛选内容，仅保留与病史相关的部分。

Insummary, the patient history is the most important aspect of patient
evaluation as it guides the physician team’s decisions concerning
diagnostic work up and formulation of a treatment plan. As mentioned the
medical history contributes more towards the diagnosis than any other
test (60% to 80% of the information needed to make the diagnosis).
Further it can help to establish rapport where the patient not only
learns to trust their physician but also is more likely to heed their
advice.