1、抗生素医嘱[Antibiotic order] 

•Prophylaxis [预防性用药] 

Duration of order[用药时间] 24hr 

Procedure[操作，手术] 

•Empiric therapy [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[其它] 

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] 

•Activity [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]: 

*Hb<8.5 [血色素<8.5] 

*>20% blood volume lost [>20%血容量丢失] 

*cardio-pulmonary bypass with anticipated Hb <8[心肺分流术伴预计血色素<8] 

*chemotherapy or surgery with Hb <10[血色素<10的化疗或手术者] 

▲全血[whole blood]: 

massive on-going blood loss[大量出血] 

▲血小板[platelets]: 

*massive blood transfusion >10 units[输血10单位以上者] 

*platelet count <50×103/μl with active bleeding or surgery[血小板<5万伴活动性出血或手术者] 

*Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流术伴血小板<10万，活动性出血者] 

*Platelet count <20×103/μl[血板<2万] 

▲新鲜冰冻血浆[fresh frozen plasma]: 

*documented abnormal PT or PTT with bleeding or Surgery[PT、PTT异常的出血或手术病人] 

*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手术者] 

*blood transfusion >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] 

Principal 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] 

6、住院/出院病历首页[Admission/discharge record] 

•Patient name[病人姓名] 

•race[种族] 

•address[地址] 

•religion[宗教] 

•medical service[科别] 

•admit (discharge) date[入院（出院）日期] 

•Length of stay [住院天数] 

•guarantor name [担保人姓名] 

•next of kin or person to notify[需通知的亲属姓名] 

•relation to patient[与病人关系] 

•previous admit date[上次住院日期] 

•admitting physician [入院医生] 

•attending physician [主治医生] 

•admitting diagnosis[入院诊断] 

•final (principal) diagnosis[最终（主要）诊断] 

•secondary diagnosis[次要诊断] 

•adverse reactions (complications)[副作用（合并症）] 

•incision type[切口类型] 

•healing course[愈合等级] 

•operative (non-operative) procedures[手术（非手术）操作] 

•nosocomial infection[院内感染] 

•consultants [会诊] 

•Critical-No. of times[抢救次数] 

•recovered-No. of times[成功次数] 

•Diagnosis qualitative analysis[诊断质量] 

OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率] 

Clinical and pathological Dx concur[临床与病理诊断符合率] 

Pre- and post-operative Dx concur [术前术后诊断符合率] 

•Dx determined with in 24 hours (3 days) after admission[入院后24小时（3 天）内确诊] 

•Discharge status[出院状况] 

recovered[治愈] 

improved[好转] 

not improved[未愈] 

died [死亡] 

•Dispositon[去向] 

home[家] 

against medical ad[自动出院] 

autosy[尸检] 

transferred to[转院到]