怎样写英文病历

How to write patient's case history怎样写英文病历PA TIENT HISTORY病史A detailed patient history and physical exam form the foundation of patient uation 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 uation 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 accura te 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: Identification: patient name, age, gender, race, and occupationChief Complaint: (in the patient’s words)HPI: (history of present illness)PMHx: (past medical history)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：身份证明：患者姓名，年龄，性别，种族和职业主述：(用患者的话表达)HPI：现病史PMHx：过去史药物史：包括现在使用的药物以及药物过敏史ROS: review of systemsSocial Hx.: includes family situation (married, divorced, single), habits; cigarettes, alcohol or illicit drug use, sexual behaviorPhysical Exam:Impression/Diagnosis:Treatment Plan:ROS：系统回顾社会史：包括婚姻状态(已婚、离婚、单身)、习惯、吸烟、饮酒或吸毒、冶游史体格检查：诊断：治疗方案：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.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。