住院文書常用的英語詞匯
導語：文書是一個概括性的名詞，指的是一種記錄信息、表達意圖的文字材料。下面小編為您收集整理了住院文書常用的英語詞匯，歡迎閱讀!
住院文書常用的英語單詞：
1、抗生素醫囑[Antibiotic order]
Prophylaxis [預防性用藥] Duration of oder[用藥時間] 24hr
Procedure[操作，手術]
Empiric theraphy [經驗性治療]
Suspected site and organism[懷疑感染的部位和致病菌] 72hr
Cultures ordered[是否做培養]
Documented infection[明確感染]
Site and organism[部位和致病菌] 5days
Other[其他]
Explanation required [解釋理由] 24hr
Antibiotic allergies[何種抗生素過敏]
No known allergy [無已知的過敏]
Drug+dose+Route+frequency[藥名+劑量+途徑+次數]
2、醫囑首頁[Admission / transfer]
Admit / transfer to [收入或轉入]
Resident [住院醫師] Attending[主治醫師]
Condition [病情]
Diagnosis[診斷]
Diet [飲食]
Acitivity [活動]
Vital signs[測生命體征]
I / O [記進出量]
Allergies[過敏]
3、住院病歷[case history]
Identification [病人一般情況]
Name[性名]
Sex[性別]
Age [年齡]
Marriage[婚姻]
Person to notify and phone No.[聯系人及電話]
Race[民族]
I.D.No.[身份證]
Admission date[入院日期]
Source of history[病史提供者]
Reliability of history[可靠程度]
Medical record No[病歷號]
Business phone No.[工作單位電話]
Home address and phone No.[家庭住地及電話]
Chief complaint[主訴]
History of present illness[現病史]
Past History[過去史]
Surgical[外科]
Medical[內科]
Medications[用藥]
Allergies[過敏史]
Social History[社會史]
Habits[個人習慣]
Smoking[吸煙]
Family History[家族史]
Ob/Gyn History[ 婚姻/生育史]
Alcohol use[喝酒]
Review of Aystems[系統回顧]
General[概況]
Eyes，Ears，Nose and throat[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]
Endocrinology[內分泌系統]
Lymphatic/Hematologic[淋巴系統/血液系統]
Physical Exam[體檢]
Vital Signs[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]
Heart rate[心率]
Heart rhythm[心律]
Heart Border[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]
cranial nerves[顱神經]
sensation[感覺]
Motor[運動]
*Special P.E. on diseased organ system[專科情況]
*Radiographic Findings[放射]
*Laboratory Findings[化驗]
*Assessment[初步診斷與診斷依據]
*Summary[病史小結]
*Treatment Plan[治療計劃]
4、輸血申請單[Blood bank requisition form]
(1)reason for infusion[輸血原因]
紅細胞[packed red cells， wshed RBCs]：
*Hb20% blood volume lost [>20%血容量丟失]
*cardio-pulmonary bypass with anticipated Hb 10 units[輸血10單位以上者]
*platelet count 15units[輸血>15個單位]
*warfarin or antifibrinolytic therapy with bleeding[華法令或溶栓治療后出血]
*DIC[血管內彌漫性凝血]
*Antithrombin III dficiency[凝血酶III 缺乏]
(2)輸血要求[request for blood components]
*patient blood group[血型]
*Has the patient had transfusion or pregnancy in the past 3 months [近3個月，
病人是否輸過血或懷孕過?]
*Type and crossmatch[血型和血交叉]
*Units or ml[單位或毫升]
5、出院小結[discharge summary]
Patient Name[病人姓名]
Medical Record No.[病歷號]
Attending Physician[主治醫生]
Date of Admission[入院日期]
Date of Discharge[出院日期]
Pirncipal Diagnosis[主要診斷]
Secondary Diagnosis[次要診斷]
Complications[并發癥]
Operation[手術名稱]
Reason for Admission[入院理由]
Physical Findings[陽性體征]
Lab/X-ray Findings[化驗及放射報告]
Hospital Course[住院診治經過]
Condition[出院狀況]
Disposition[出院去向]
Medications[出院用藥]
Prognosis[預后]
Special Instruction to the Patient(diet， physical activity)[出院指導(飲食，活動量)]
Follow-up Care[隨隨訪]
6、住院/出院病歷首頁[Admission/discharge record]
Patient name[病人姓名]
race[種族]
address[地址]
religion[宗教]
medical service[科別]
admit (discharge) date[入院(出院)日期]
Length of stay [住院天數]
guarantor name [擔保人姓名]
next of kin or person to notify[需通知的'親屬姓名]
relation to patient[與病人關系]
previous admit date[上次住院日期]
admitting physician [入院醫生]
attending phgsician[主治醫生]
admitting diagnosis[入院診斷]
final (principal) diagnosis[最終(主要)診斷]
secondary diagnosis[次要診斷]
adverse reactions (complications)[副作用(合并癥)]
incision type[切口類型]
healing course[愈合等級]
operative (non-operative) procedures[手術(非手術)操作]
nosocomial infection[院內感染]
consutants[會診]
Critical-No. of times[搶救次數]
recovered-No. of times[成功次數]
Diagnosis qualitative analysis[診斷質量]
OP.adm.and discharge Dx concur [門診入院與出院診斷符合率]
Clinical and pathological Dx concur[臨床與病理診斷符合率]
Pre- and post-operative Dx concur [術前術后診斷符合率]
Dx determined with in 24 hours (3 days) after admission[入院后24小時(3 天)內確診]
Discharge status[出院狀況]
recovered[治愈]
improved[好轉]
not improved[未愈]
died [死亡]
Dispositon[去向]
home[家]
against medical ad[自動出院]
autosy[尸檢]
transferred to[轉院到]
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