醫(yī)學(xué)英語(yǔ)翻譯與寫作：Medical English Writing(5) writingthe case history

1、Medical English WritingShandong UniversityMay, 2014Medical English Writing (5)Writing the medical recordsMay, 2014 病例 病歷caseMedical recordCase historyMedical clerkingClinical chartDistinguish the following terms:medical record case reportclinical reportclinical recordcase historymedical clerking dis

2、charge summaryoperative reportlaboratory report admission assessmentadmission noteprogressive note nursing noteconsultation requisition noteconsultation notepre-anesthetic noteanesthesia record discharge note醫(yī)療記錄；病歷，病案病例報(bào)告臨床報(bào)告臨床記錄病歷病歷；病案（記錄）出院總結(jié)手術(shù)報(bào)告化驗(yàn)報(bào)告；實(shí)驗(yàn)室報(bào)告入院評(píng)估入院記錄病程記錄護(hù)理記錄會(huì)診申請(qǐng)記錄會(huì)診記錄麻醉前紀(jì)錄麻醉記錄出院記錄Wh

3、at Is A Medical Record?A medical record is information about the health of an identifiable individual recorded by a doctor or other healthcare professionals. It should contain sufficient information to “identify the patient, support the diagnosis, justify the treatment, document the course and resul

4、ts, and promote continuity of care among healthcare providers”. Case ReportA case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. It is written based on the medical records. Case reports usually describe an unusual or novel occurrence

5、. Generally a case report is less than 2,000 words.medical recordcase report clinical report clinical record case history (medical clerking)discharge summaryoperative reportlaboratory reports admission assessmentadmission noteprogressive notenursing noteconsultation requisition noteconsultation note

6、pre-anesthetic noteanesthesia record discharge noteMost case reports are on one of the topics:Unexpected or unusual presentations of a diseaseUnreported or unusual side effects or adverse interactions involving medications New associations or variations in disease processes Presentations, diagnoses

7、and/or management of new and emerging diseases An unexpected association between diseases or symptomsAn unexpected event in the course of observing or treating a patient Findings that shed new light on the possible pathogenesis of a disease or an adverse effect Publishing case reports Many internati

8、onal journals will publish case reports, however there are a few that are devoted to publishing case reports alone. Journal of Medical Case Reports, Case Reports in Medicine, and Cases Journal are three such journals, publishing open access peer reviewed case reports in all areas of medicine. BMJ ca

9、se reports is an online, peer-reviewed journal publishing cases in all disciplines. The Journal of Radiology Case Reports is a journal focusing on medical imaging. Journal Of Surgical Case Reports is a journal that considers case reports in the field of surgery. Structure of a case reportTitleIntrod

10、uction or AbstractCase Presentation or Diagnosis and TreatmentDiscussionReferenceCase HistoryA case history is a complete record of the symptoms, signs, findings of check-up, personal and social factors, diagnosis and treatment of a case.It is not only the important foundation of diagnosing and trea

11、ting diseases of a patient, but the information for medical research, and the evidence with legal validity.Basic RequirementsNotes should be written during the consultation or immediately afterwards, as soon as possible after the event has occurred. True and complete record, accurate and brief prese

12、ntation All the words shall be in the same ink, neat and clear. They shall be free from any alterations.Basic RequirementsDate (Year, Month And Day) exactly on each note, even hour and minute for an emergency treatment. The time should be recorded as 24-hour time, e.g. 14-02-2009, 14:05(BrE) or 02-1

13、4-2009, 14:05(AmE)Fill out each item of the tables, with the name, admission number, department, bed No. on each page.Symptoms, signs, diseases and organs are stated with medical terms.Items of a case historyGeneral DataChief Complaint (CC )History of Present Illness ( HPI/PI)Past (Medical ) History

14、 (PH)Family History (FH)Personal History (Per. H)/Social History (SH)Drug historyAllergiesSystems Review/Inquiry Physical Examination (PE)Laboratory ExaminationDiagnosis/Impression (Imp.)/SummaryHospital courseDischarge InstructionsDischarge MedicationGeneral Data Name 姓名Sex 性別Age 年齡Occupation 職業(yè)Dat

15、e of birth 出生日期Marriage （Marital status） 婚姻,婚姻狀況Race 民族Place of birth (Birth place) 籍貫Identification No. (code of ID card No.) 身份證號(hào)碼Department of work and TEL. No. (Unit and Business phone No.) 工作單位及電話General DataHome address and phone No. 家庭住址及電話Post code 郵政編碼Person to notify (Correspondent) and ph

16、one No.聯(lián)系人及電話Source (Complainer; offerer; supplier; provider) of history 病史陳述者Reliability of history 病史可靠程度Medical security (Type of payment)醫(yī)療費(fèi)用Type of admission (Patient condition)住院類別（入院時(shí)病情）Medical record No. 病歷號(hào)Clinic diagnosis 門診診斷Date of admission (admission date) 入院日期Date of record 記錄日期Reliab

17、ility:Reliable Not entirelyNot clearly definedConfused and uncertainUnobtainable可靠不完全可靠不夠準(zhǔn)確混亂不清無法獲得General Data（Introduction） Sample:The patient, a thirty-five-year-old Caucasian female, housewife, was first seen in the office with a chief complaint of upper respiratory infection of 3 days duration.

18、Chief ComplaintA detailed objective account of the patients central problems which have been already identifiedPut details about the problem and related symptoms in a chronological orderThe duration of the chief complaint should be noted, for example “chest pain for 1 hour”. History of Present Illne

19、ssthe most important structural element of the medical history Detailed description of the “chief complaint”, or a chronological history and sequence of the chief complaint. What circumstances precipitated it，for example：climbing stairs, emotional upset such as anger, or sexual intercourse. What cir

20、cumstances relieve it: e.g. resting for a few minutes History of Present IllnessAttack/onsetLocationNature, feature, severityFrequencyRelationDevelopmentDiagnoses and treatmentPresent status起病癥狀所在部位癥狀的性質(zhì)、特征、程度癥狀出現(xiàn)頻率癥狀間關(guān)系病情的發(fā)展治療經(jīng)過病人現(xiàn)有體質(zhì)Past HistoryPrevious state of healthPrevious illnessesVaccination

21、 and infectious diseasesAllergy to drugs or other substances過去一般健康狀況過去所患疾病預(yù)防接種與傳染病對(duì)藥物及其他物質(zhì)的過敏有無藥物（食物）過敏史 past history of allergy to drugs (food )有無青霉素過敏史 allergic history of penicillin有無肺結(jié)核接觸史contact history of lung tuberculosis外傷史trauma history預(yù)防接種史history of preventive inoculation健康狀況佳（差）health st

22、ate was good (bad)既往體健be well (healthy) before 2000年6月因急性闌尾切除術(shù)Appendectomy was done in June, 2000 due to acute appendicitis否認(rèn)既往心、肺疾病史deny any history of prior heart and lung disease10歲時(shí)（20年前）曾患過suffered from at age 10(20 years ago)易患be liable (subject, apt) to不詳not in detail (not quite clear)Family

23、History (FH)mainly parents, siblings, children, and spouse involved, grandparents if necessarythe health status and illnesses of the family members: be living and well; hereditary/genetic diseases; infectious diseases; time and cause of death mental handicap, dementia should be paid attention toPers

24、onal HistoryLife style and habitsOccupation and working conditionsTravellingMarriage and Child-bearingMenstruation生活方式及嗜好職業(yè)和工作環(huán)境外出旅游婚姻和生育月經(jīng)Systems ReviewThis section is to consult and record the past conditions of each system.This section is too often omitted.Noncontributory(無可記述) and See Present（Pa

25、st）Illness （見現(xiàn)病史/既往史）can be used in some itemsPhysical Examination To find and record related signs of the patient by inspection, auscultation, palpation and percussion for making correct diagnosisMainly include: general items (temperature, pulse, respiration, blood pressure, heart rate, physical de

26、velopment, nutrition appearance and consciousness, skin and lymph), head and neck, chest and abdomen, nervous system, skeleton and muscle, urogenital system and othersWhen recording the history and physical examination, the physician should follow several rules: Record all pertinent data. Avoid extr

27、aneous data. Use common terms. Avoid nonstandard abbreviations. Be objective. Use diagrams or pictures when indicated. Laboratory Examinationrecord all those data that are associated with diagnosis, including routing tests and other laboratory tests 24 h after admission. Laboratory Examinationexamin

28、ation of blood cell血液細(xì)胞學(xué)檢查examination of marrow cell骨髓細(xì)胞學(xué)檢查examination of hemostasis and coagulation出血和凝血的檢查kidney function examination 腎功能檢查liver function examination肝功能檢查endocrine test內(nèi)分泌試驗(yàn)immunological examination免疫學(xué)檢查blood gas assay血?dú)夥治鰏tool examination大便檢查urine examination小便檢查fluid examination液

29、體檢查Bacterial culture 細(xì)菌培養(yǎng)Diagnosis/ImpressionThe diagnosis after analysis of the state of the caseDifferent types: primary diagnosis, final diagnosis, complete diagnosisNoun phrases are usedSOAP （Progressive Note）SOAP is a method of documentation employed by health care providers to write out notes

30、in a patients chart SOAP（Progressive Note）S = subjective This section describes the patients current condition in narrative form. The history or state of experienced symptoms are recorded in the patients own words. It will include all pertinent and negative symptoms under review of body systems. O =

31、 objective This section records vital signs, findings from physical examinations, results from laboratory, measurements. SOAP （Progressive Note）A= assessment This section is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagn

32、oses usually in order of most likely to least likely . P =plan In this section is recorded the treatment plan including estimated length of treatment, and discharge plans. SOAPThe length and focus of each component of a SOAP note varies depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status. Ownership of Medical Records Medical records may be regarded as aides-memoires created by the healthcare providers to assist them in the management of patient care. As s