住院文书常用英语词汇
文书是一个概括性的名词，指的是一种记录信息、表达意图的`文字材料。下面小编为您收集整理了住院文书常用的英语词汇，欢迎阅读!
1、抗生素医嘱[Antibiotic order]
Prophylaxis [预防性用药] Duration of oder[用药时间] 24hr
Procedure[操作，手术]
Empiric theraphy [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[其他]
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]
Acitivity [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]：
*Hb20% blood volume lost [>20%血容量丢失]
*cardio-pulmonary bypass with anticipated Hb 10 units[输血10单位以上者]
*platelet count 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]
Pirncipal 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]
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