无论是原文还是译文，病历记录的纲要式结构大致一样：
一般项目（general data）
主诉（chief complaint）
现病史（present history）
既往史（past history）
家族史（family history）
体格检查（physical examination）
实验检查和其他辅助检查（laboratory and aided examination）
诊断（diagnosis）
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]
Cultures ordered[是否做培养]
Documented infection[明确感染]
Site and organism[部位和致病菌]
Other[其它]
Explanation required [解释理由]
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]l
P[脉博]
Bp[血压]
R[呼吸]
T[温度]
Height[身高]
Weight[体重]
General[概况]l
HEENT[五官]
Neck[颈部]
Back/Chest[背部/胸部]
Breast[乳房]
Heart[心脏]l
Heart rate[心率]
Heart rhythm[心律]
Heart Border[心界]
Murmur[杂音]
Abdomen[腹部]l
Liver[肝]
Spleen[脾]
Rectal[直肠]
Genitalia[生殖系统]
Extremities[四肢]l
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 [心肺分流术伴预计血色素 ]
*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/μlwith 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 orSurgery[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 withbleeding[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]l
Medical Record No.[病历号]l
Attending Physician[主治医生]l
Date of Admission[入院日期]l
Date of Discharge[出院日期]l
Principal Diagnosis[主要诊断]l
Secondary Diagnosis[次要诊断]l
Complications[并发症]l
Operation[手术名称]l
Reason for Admission[入院理由]l
Physical Findings[阳性体征]l
Lab/X-ray Findings[化验及放射报告]l
Hospital Course[住院诊治经过]l
Condition[出院状况]l
Disposition[出院去向]l
Medications[出院用药]l
Prognosis[预后]l
Special Instruction to the Patient(diet,physical activity)[出院指导（饮食，活动量）]l
Follow-up Care[随随访]l
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 the 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) afteradmission[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]
