24 病歷英文要簡潔、明瞭 “The patient was admitted for evaluation and management.” 可寫成“Admitted through ER (或 OPD).” 如果是轉介來，就寫為什麼轉介。“The patient has been suffering from chronic headache for years.”可寫成 “Has had chronic headache for 7-8 years”; “Chronic headache, 7-8 years.”“The patient lost body weight”; “ Body weight loss”（可在主訴）.可寫成 “Bw 69 Kg 3 months ago, 65 Kg now (today)”.
34 Present illness 的寫法： 不完整電報式子句 High fever up to 39°C, sudden onset, daily spike for 4 days; rigor (+) initially; slight dizziness (+) ; poor appetite (+); severe malaise (+)。Visited Dr. Chen’s clinic (Address:…, Tel#:…) daily for 3 days, IV injection daily and two kinds of t.i.d. tablets; no improvement。[查問症狀初發時正在做什麼，可以刺激病人的回憶]。Muscle ache(+), generalized, severe; mod. bitemporal headache (+).Dry cough, dyspnea, since this morning; rapidly progressive. Came to ER。 Needed oxygen right away。No urinary, or respiratory symptoms. Loose BM x 2; nausea (+)
35 History Taking 尚可加強的部分 徹底瞭解病患的生活起居 以找出可能病因、危險因子，預防疾病再發、擴散 Contact with animals, sick people:（住家內的人數）Sexual Hx: (幾乎無人問及!)。過去、或最近使用的抗生素：[可放在Present Illness]。對目前將選用的藥物有直接的影響（療效、過敏）。必須從過去的病歷、負責的醫師查問為何用藥、用多久、效果如何。（用電話，以爭取時效）Interpersonal relationship, family life:可瞭解心理狀態
37 Management Plan 要逐項詳細記下將要：做哪些檢查、如何用藥、給藥、將會診什麼科、哪位醫師。 不能只寫 : To give iv fluidsTo give antibioticsTo give pain killersTo give bronchodilatorsTo give antihypertensivesTo give oral hypoglycemic agents要寫藥名（化學名）、劑量、給藥途徑及頻率。
38 Progress note 的寫法可以 S.O.A.P. 或 以 problem-oriented medical record (POMR) 方式記載。不論何種方式，其內容：一定要記載已接受的治療、主治醫師對病情的進展及對醫療效果的評估。[醫院評鑑要求的是POMR]
39 目前Assessment 錯誤的寫法： 就是只重複寫出住院時之 impression而沒有評估 Sepsis, R/O pneumoniaType 2 DM, out of controlHistory of cervical CA, S/P total hysterectomy, 8 years.Diarrhea, cause to be determined.
40 Assessment / plan 的寫法(例一) 給了什麼治療？有沒有好轉？為什麼？以後如何處理？ Sepsis, R/O pneumonia: Third day of cefuroxime 1.5 gm, q8h. Clearly improving. To continue the same Rx. For 6-7 days.Type 2 DM : Glucose level is under control with …..Hx/O cervical CA: checked by Gyne. No signs of recurrence.Diarrhea has stopped 3 days after admission. Stool culture (-), cause unknown; related to the pneumonia?(隨期間而會逐漸改善的治療，如抗生素、手術後、及其他大部分處理，應該寫今天是第幾天的治療)
41 Assessment / plan 的寫法（例二） 給了什麼治療？有沒有好轉？為什麼？以後如何處理？ High fever: Received 5 days of empiric clarithromycin 500 mg, bid. Does not seem to be improving. May be viral infection. Will D/C the antibiotic and observe. To check the report of influenza, parainfluenza virus antibodies. Renal function is worsening, will check for Hantavirus and Leptospira antibodies. No jaundice.Vomited twice yesterday. 2 hours after lunch. No diarrhea. No meningeal signs. Cause not clear. To continue observation.
43 Progress note （Problem-oriented record） 的寫法(例一) Sepsis, R/O pneumonia: Bronchopneumonia confirmed by CXRs on admission. Third day of cefuroxime 1.5 gm, q8h. WBC decreased from 15K 3 days ago to 10K today. Defervesced; less cough. Less rales. No more headache.Clearly improving. To continue the same Rx. For the next 6-7 days.Type 2 DM : Blood glucose down from 215 on admission, to 122 today, under control with Diabenese, po, bid, and with effective control of infection.Hx/O cervical CA: Checked by Gyne yesterday. No signs of recurrence.Diarrhea has stopped 3 days after admission. Stool culture (-), cause unknown; related to the pneumonia??
44 Progress note （Problem-oriented record） 的寫法（例二） High fever: Still febrile up to 39.3°C last evening. WBC still around 10K. Bitemporal headache when febrile. All cultures: no growth. Cause of the fever still unclear. Received 3 days of empiric Unasyn 1.5g, q6h, ceftazidime 2 gm, q8h, and minocyclin 100 mg, bid.Does not seem to be improving. May be viral infection or still be Rickettsial. Will D/C the antibiotic and observe. To check the report of influenza, parainfluenza virus antibodies.Renal function is worsening, will check for Hantavirus and Leptospira antibodies. No jaundice.Vomited twice yesterday. No diarrhea. No meningeal signs. Cause not clear. To continue observation.
46 醫學用詞的縮寫 Abbreviations 盡量不用縮寫，以免誤解限制在國際通用的檢驗項目名稱早期醫學院臨床醫學初期學到的基本醫學名詞如有必要使用，應在第一次提及時，先寫出全名，後面以括弧註明將在文內使用的簡寫所用縮寫也應該使用三個以上的字母，且合乎縮寫的通則 （不合宜的例子：anti, meta, on endo）特別容易誤解的 qd, 及qid，建議都不使用，分別改為 once a day 或 once daily，及four times a day。
52 Procedure Note (一定要寫明時間) Procedure done: spinal tappingIndication: To rule out CNS infection; eye ground showed no signs of increased ICP, and cranial CT showed no mass.Consent form obtained after thorough explanation to the patient in the presence of RN Chen YJ and the patient’s motherPatient was laid on his left lateral side in fetal positionLocal anesthesia with 2% Xylocain, 5 mL.22 G spinal tap needle was inserted through the space between L3-L4 without problemCSF, crystal clear, 2 mL each, was withdrawn into four tubes. One sent for antigen studies (…), culture, and smears; one sent for chemistry; one for cell counts; and the last one for STS/VDRL.OP: 110 mmHg; and CP: 100 mmHgThere was no complication and the patient tolerated the procedures well.The patient was instructed to lie on his back for 8 hours.Simultaneous blood sugar has been drawn
54 Weekly SummaryThis 72years old man was admitted on , because of melena for 2 days prior to admission. Endoscopy revealed active bleeding ulcer on the duodenum.Packed RBC 8u was given after admission because of 7.8 gm% Hgb. Follow-up Hgb was 11.2 gm%. Tarry stool has stopped now.PPI (Losec 1 amp iv bid) was shifted to oral Nexium 1# qd on General condition is stable now.He will be kept under close observation, and discharged next Wednesday (Dec.14), if clinically unchanged. He will be followed up at G-I clinic (Dr. C.Y. Lee, Wednesday afternoon) after discharge
56 Summary note after the Case Conference This patient was presented to Grand Round of the Department on G-I experts all agreed with the diagnosis.Remaining problems exist: (1) Fever: may be from urinary tract infection but biliary tract infection can not be excluded; (2) High CEA and CA 19-9: may be false positive but pancreas should be carefully evaluated with abdominal CT.The tests (CA 19-9 and CEA) need to be followed up every 2 months).Only symptomatic treatment is indicated at present.Prof. C. Y. Wang: Addition of pancreatic enzyme may be helpful for evaluation of CA 19-9 data (may convert CA 19-9 to normal).
58 錯誤的、或不恰當的病歷英文(1)Cancer was told He was told that he has cancer; He was diagnosed with cancer; Cancer was suspected 或 diagnosed 。或 “Cancer”, he was told.(小說式的)The patient went to an Dr. Chen’s clinic in vain。 應該寫the treatment was not effective; 或 the symptoms did not improve .
59 錯誤的、或不恰當的病歷英文(2)The patient ever went to a hospital The patient has been to a hospital. The patient did go to a hospital.Acception note acceptance note, 或 on service note.Progression note， progressive note progress note .Cancer was impressed Cancer was suspected .
60 錯誤的、或不恰當的病歷英文(3)Conscious clear. Consciousness: alert, coherent and oriented as to time, place, and person (常簡寫成 oriented x 3)Mentality clear 應該寫consciousness…。The patient is anemia. The patient is anemic ; The patient has anemia.
61 錯誤的、或不恰當的病歷英文(4)Discharge diagnosis: R/O cancer probable cancer、suspected cancer。The patient developed abdominal pain and high fever , Abdominal pain and high fever developed .兩句都對!!!會診單上寫完意見之後自己寫 Thank you for the consultation [???] 只需寫Thank you for the referral.或 Thanks.Nothing particular. (N P) unremarkable。
62 錯誤的、或不恰當的病歷英文(5)Unfortunately （可免寫）, abdominal pain and high fever developed。Dear Dr. ; We sincerely request……; your nationally reputable expertise…. Your globally acclaimed technical skills : 都可免寫，多記載病史、檢驗數據。According to the statement of the patient according to the patient; according to his sister。The patient is a victim of motor vehicle accident (MVA). 可寫成 The patient had an MVA。
63 錯誤的、或不恰當的病歷英文(6) MBD (may be discharged) discharge; discharge in AM。 AAD discharge against medical advice; discharge AMA。台灣病理報告: non-made (???) 。