英文病历书写规范

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Hospital ChartsPaperwork and Protocols From admission through surgery in the O.R. or clinic to discharge

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Patient Admission ASU vs Overnight Overnight pre-op (rare)– Long distance– Pre-op compliance– Evaluation and testing

ASU with post-op admission– Post-op monitoring– Post-op complications– Nursing supervision

ASU or Day surgery, no admission– Compliant and relatively healthy patient– Relatively minimal surgery (??)

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Patient Admission- Preliminary Steps Financial responsibility– approved by third party Legal guardianship– mandatory if over 18 years and incompetent

Complete Informed Consent– usually within 1 week of surgery

Scheduling– O.R. time– Provide ASA risk level, O.R. time needed– Admitting office for bed or other scheduling needs

Preadmission labs, H&P Dental Treatment Plan, at least a general plan

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Medical Risk Assessment ASA I - Healthy individual ASA II– Mild systemic disease– Mild controlled HTN

ASA II– Severe systemic disease– IDDM

ASA IV– Incapacitating systemic disease– Cardiomyopathy

ASA V– Moribund patient– Terminal leukemia

E– designation with any of the above categories for emergent care necessary

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Hospital Chartwork Components Admission note Admission orders Progress notes Consents Pre-operative note Pre-operative orders

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Hospital Chartwork Components Operative note Dictated Operative Report Post-op progress notes Post-op orders Discharge Note Discharge Orders Dictated Discharge Summary

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Admission Paperwork Admission Note Admission Orders Dental Database Consent History and Physical (H&P) Lab work, CXR, EKG

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

H&P

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

H&P

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

H&P

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

H&P

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Admission Note Admit to Dental Service for Dr. Jolly S (subjective)–––––––– Identify patient and condition (eg: 25 WM) Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH) Past Surgical/ Anesthetic History (PSH/ PAH) Family History (FH) Social History (SH) Review of Systems (ROS)

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Admission Note O (objective)– PE– summarize physician's exam– Physician's complete H&P should be here as well– Medications patient is taking– Pertinent lab results CBC Platelets Electrolytes Coagulation studies EKG, CXR

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Admission Note– Dental Database Dental history Overall oral condition, all parts of oral exam Pertinent negative findings Extraoral findings of significance Decay and periodontal disease Condition of prostheses Radiographic findings

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Admission Note A (assessment or diagnosis)– Specific diagnoses

P (plan of treatment)– Specify what you are going to be doing for the patient

很详细的双语书,300多页,比较详细。比现在的书认真,是绝版。

Admit Note