病歷的書寫 各種病歷書寫的格式、記錄方法與內容可能因國家、地區、醫學院、及醫院的不同而略有差異，但不論如何，病歷書寫的目標總是一樣的。 它主要是在清楚地記錄與傳達正確詳實的病人訊息以及醫師評估與診治的意見，以為病人照護之依據，並藉以提昇醫療照護品質。

優良的書寫技巧 就是要『簡、明、達意』，用最精簡的方式、文字，完整地描寫現象、過程，正確地表達意見。 病歷書寫，要『一眼就能看得清楚』！因為病歷內容複雜，要注意每天的記錄內容要能夠寫出要點，不要讓讀者自己東翻西翻找相關的數據。

病歷英文要正確、文理通順 英文還是中文？ 不論是中文、英文，文理還是要正確通順。 全世界科學、醫學的新進展差不多都用英文發表！ 不論是中文、英文，文理還是要正確通順。 英文不一定要用完整的句子，只要意思表達清楚，電報式子句也可。 英文不佳，不反對先用中文補註清楚。以後再學習。

住院病歷記錄主要內容 Orders T.P.R. Sheet Admission Note Progress Note Consultation Note Invasive Procedure Record Operation Note 麻醉記錄 Informed Consent(同意書) 給藥記錄 護理記錄 Discharge Summary X光及其他醫學影像報告

Admission Orders 住院醫囑單 『誰下的、何時寫的』要可以看出來 Diagnosis Perforated peptic ulcer with sepsis Uncontrolled DM Old CVA with right hemiplegia Hypertension Allergy Shrimps (urticaria); penicillin (positive skin test或urticaria或probable anaphylactic shock) Condition Critical or guarded或其他應該讓護理人員瞭解的疾病程度 Diet Activity Medications 最好用學名，並註明劑量，儘量不要寫幾顆或幾瓶 IV fluids

Discharge Orders 醫囑寫法 出院指示 Discharge this afternoon Discharge tomorrow morning Discharge against medical advice (簡寫為discharge AMA，最好不要寫AAD) 不宜寫may be discharge (MBD)！ 出院指示 出院處方 必須寫藥的學名、劑量、服用方法、供應天數。 後續安排 OPD F/U in 3 days; Referred back to Dr. Lin’s clinic

TPR sheet 可以記載 日期、TPR、血壓、身高、體重、I/O、BM，drainage之量； 主要的治療藥物、抗生素及其劑量； 會影響TPR的藥物：退燒藥、類固醇、NSAID、抗生素、輸血、放射線治療、化療； 重要的檢查或處理：手術、切片檢查、插管拔管、鏡檢、細菌培養、外送檢驗、其他可能常會問到、提到的，和病況進展有關事項； 重要的檢查結果、需要常常追蹤的數據：WBC、CRP、培養結果、等等； 突發事件：跌倒、昏迷、seizure、等等； （目的就是要使醫護人員或其他人員，對住院後的病程，只看TPR sheet就可以一目瞭然。）

Admission Note Chief Complaints Present Illness Past History Personal, social and occupational history Family History Review of Systems Physical Examination Image and Laboratory Impression Plan of management and treatment

Admission Note Chief Complaints 用病人自己的話來描述 發病時間不要只寫出日期、月份或星期 × Abdominal pain since last Sunday. 精簡，適當的形容詞 Progressive abdominal distention 4 days before (或prior to) admission. Intermittent abdominal pain for 4 hours. Sudden onset of sharp epigastric pain for 2 hours. Tarry stool over the past two days. 不能只寫 for operation, for chemotherapy…，要加上為什麼要做上述治療！ e.g. Colon cancer diagnosed 2 weeks ago.

Admission Note Present Illness 記錄原則： 按症狀出現的先後順序記錄 時間最好少用日期 不要只寫LMD或local hospital 慢性病必需記錄使用藥物的名稱和劑量、病人服藥情形和反應。 如腸阻塞的病人，要說清楚可能的前因：如之前動過的腹部手術的時間地點及結果！

Writing “Present Illness” 1.開場白-選擇基本資料中之關鍵詞，融合過去相關病史及主訴作為開場白，如此可將病例的全貌摘要地呈現出來，有助於列舉出各個問題，並開啟解決問題的步驟。 例：This 65 year-old man, who is a construction worker with a history of appendectomy, was admitted from our ER because of intermittent abdominal pain for 2 days. SKH

Writing “Present Illness” 2. 接著，有系統地記載有助於診斷及治療的資料(包括症狀、過去的檢查、治療與治療的反應等)來推敲問題。一些與主訴相關的negative symptoms或history也應寫出，對鑑別診斷相當重要。 3. 住院的理由或適應症也應在最後簡要地陳述。 SKH

Admission Note Present Illness 【例】The 50 y/o male patient is a case of hypertension, DM and old CVA for 10 years with regular medications. 不要稱病人為male or female – man or woman, boy or girl. 避免稱病人為 “a case” – The patient has had hypertension… “regular medications” – taking medicine as ordered

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 stool x 2; nausea (+)

Admission Note Past History 一般以發生時間的先後決定記載的次序。 手術史 : 手術之時間、當時的診斷、有無器官切除、有無輸血、住院多久、追蹤多久。 藥物史需特別著重過去對藥品的過敏反應，包括多久以前發生，藥物名稱、發生時的症狀及其處理辦法。

Admission Note Personal, social and occupational history 生產史、發展史、教育程度、職業現況(職業與職稱)、婚姻狀況 嗜好、習慣、飲食睡眠情況 有無抽煙(量及期間)、喝酒(量及種類)、咖啡、檳榔、藥物 月經、懷孕、生育史

Admission Note Family History 遺傳或接觸性疾病：過敏、癌症、感染性疾病、精神疾病、糖尿病、高血壓、心臟病、腎臟病、癲癇、痛風、中風…等 包括至少三代族譜的繪畫

History taking 要詳細精確！

Admission Note Review of System 是為了怕遺漏掉一些訊息，應再回顧檢查各器官系統問題、症狀及疾病。 有問題者還要詳細問，並放入Past History或Present Illness中。

Admission Note Physical Examination 寫出異常的敘述，而不是用診斷的名稱。如：結膜是蒼白的，可能是貧血，但不要就寫anemic，寫pale就好！鞏膜是黃的，不要寫jaundice，要寫icteric。 長度及大小最好使用公分來記，避免用egg-sized, palm-sized等！ 以圖表示更好，但要精確！

Admission Note Impression 診斷應儘量完整，少用簡寫，除了病名外最好加上程度。 Cirrhosis, alcoholic, Child class C; Spleen laceration, Grade I, hemodynamic stable; Old CVA, with right hemiplegia 小心用R/O，不要沒有其他診斷就直接寫rule out XXX. Fever, suspected of UTI, R/O drug fever. 如果診斷暫時無法確定，可以寫fever或chest pain, cause to be determined Impression之後宜有Differential Diagnosis.

依處置之優先順序順列，列出預計檢查與治療的計劃，包括照會、用藥等。 Admission Note Plan 依處置之優先順序順列，列出預計檢查與治療的計劃，包括照會、用藥等。 不要只寫： To give iv fluids. To give antibiotics To give antihypertensives 藥名最好用學名、寫明劑量、給藥途徑及頻率。

Progress Note 的寫法 一般以Problem-Oriented Medical Record (POMR) 的方式來書寫，最常採用Subjective-Objective-Assessment-Plan (S.O.A.P.) 模式，針對每一個active problem逐項(或擇要)寫出SOAP，特別注意病情的變化、評估及處理方式。 應每天書寫，內容不能一成不變，切忌張貼同樣字句！！無用的數據不必每天打（貼）！主治醫師應counter-sign (複簽)，並加以修改或評語與追加。 不論何種方式，其內容： 一定要記載已接受的治療、病情的進展及對醫療效果的評估。

SOAP 記錄方式 S (subjective): symptoms (chief complaints) O (objective): signs (physical exam) & lab results A (assessment): impression/diagnosis and patient or disease condition P (plan): approaches to diagnosis (lab tests) approaches to therapy (medications, procedures, operation, etc.) approaches to healthcare education SKH

Problem-oriented Progress note 之內容 按照住院時列舉之 Impression ，逐項討論。 給了什麼治療？有沒有好轉（數據）？為什麼？以後如何處理？ 先寫有關此診斷之症狀，如肺炎則描寫咳嗽、痰、胸痛、肌肉痛、頭痛、等等。 再記載有關此診斷之檢驗數據，說明和前一次是否較高、較低、或差不多。 提醒今天是用什麼治療的第幾天。不寫第幾天，就常會使用過久。 說明此問題在你的判斷，今天是否比昨天、前天、或住院時，較好、較壞、或差不多。 分析你認為是為什麼？ 最後說明為了解決目前的問題，或潛在的問題，要再作何檢查或治療。

例：#1 Chest pain S:___________ O:___________ A:___________ #2 Upper GI bleeding S.O.A.P. #3 Arrhythmia SKH

2009. 08. 25 5:00 PM # Swelling of the right side cheek 3 days after surgery. S: Swelling of the right cheek. O: 1. Intraoral exam revealed erosive and swelling of the surgical site of 48 region. 2. There was no evidence of bleeding, nor exudation. 3. Panoramic radiograph showed no retained root fragment of 48. A: 1. Dentigerous cyst, LR s/p cyst enucleation for 3 days 2. 48 impaction s/p odontectomy for 3 days 3. Edema over right cheek, more severe than yesterday P: 1. OHI. 2. Hot compression, 20 min/hr.

Assessment 錯誤的寫法 只重複寫出住院時之impression而沒有評估 Sepsis, R/O pneumonia DM type 2 Cervical CA, S/P total hysterectomy Diarrhea

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: 3rd day of cefuroxime 1.5 gm. q8h. Clearly improving. To continue the same Rx. for 6-7 days. DM type 2: Sugar level is under control with ….. History of cervical CA S/P total hysterectomy : Checked by Gyn. 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)

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.

Weekly Summary Weekend summary幫助值班醫師瞭解病情。 內容應該含： 不是將住院記錄COPY過來！ 病人何時住院 住院的主要問題是什麼 過去一週做了什麼處置 病情及治療反應如何 下週的計畫是什麼 不是將住院記錄COPY過來！

Consultation Note 有照會時除了寫會診單外，應該在病程記錄中寫照會那一科的醫師，並把照會醫師的回覆意見簡要的寫在病歷裡。 寫會診單時應多寫有關病人的病史及檢驗數據，下列的客套話可免寫： We sincerely request… Your nationally reputabel expertise,

Invasive Procedure Record 所有侵入性的檢查和處置都應以紅筆記錄，包括： 各種內視鏡檢查、血管攝影、組織切片、各種體液抽取、導管放置、氣管插管…等 記錄內容： 執行時間、地點 執行的原因、方法、麻醉方式 檢查時的發現、處置方法、有無併發症 執行者及協助者姓名

Discharge Summary 應注意事項 (1) 1. 出院診斷 Primary (主要診斷) – 引起病人此次住院的主要病況 Secondary (次要診斷) – 原已存在或者後來才發展的病況，且影響醫療/住院天數者。 * 與此次住院醫療無關的疾病不應包括在內 例: 主要診斷： 1) acute congestive heart failure 2) acute myocarditis 次要診斷： 1) aspiration pneumonia 2) ventricular tachycardia SKH

Discharge Summary 應注意事項 (2) 2. Brief history：不要重覆冗長的住院記錄中所寫的present illness，應簡單地描述病人住院之理由及相關的現在病史。 3. Hospital course：應扼要地依時程描述(不要用列表方式)病人住院期間所作過的主要檢查與治療經過。 4. 檢驗結果 (Lab results)：不應列出所有的血液及生化報告，應將他們消化後，寫出與病況有關的positive與pertinent negative findings。 SKH

Discharge Summary 應注意事項 (3) 5. Discharge medications：應以獨立heading列出所有出院用藥，藥物名稱須用generic name；要寫出劑量(100 mg，不寫one tablet)與用法。 6. Follow-up plan (追蹤計劃)。 7. Instructions to the patient (給病人的指示)：這點在國內做得最不夠，常被忽略。衛生署的病歷書寫範例也沒特別強調，只是列舉“出院後之建議及用藥” (Recommendations and medications)。 8. 應寫出referring physician或primary care physician 的名字，並且寄一份出院摘要的影印本給他們。 SKH

醫法倫（IDP）寫作格式 記載「醫學倫理與法律」的討論。其病歷記錄方式 使用 IDP（Issue, Discussion, Planning）三段論述的方式

醫法倫（IDP）寫作格式 Issue：關於該個案之醫學倫理與法律的爭議點。臨床上可能面臨的爭議點如下：病患自主權、告知同意、病患的決定能力、病患的自願、代理決定、告知病患實情、守密、兒童的醫療決定、研究倫理、安樂死、臨終生命照護、自動出院、孕婦與胎兒利益衝突、資源分配、基因檢測與遺傳的爭議…等。

醫法倫（IDP）寫作格式 Discussion：針對該特定個案，對爭議點進行討論。 (1). 討論的方式可以用對談的型態，將討論的重點加以整理，以專業的知識診斷，將情況用淺顯易懂的話語告知家屬及病患，解答病患及家屬心中的疑問。例如：「醫護人員與病患之對談」、「醫護人員與病患家屬之對談」、「主治醫師與住院醫師對談」。

醫法倫（IDP）寫作格式 Discussion：針對該特定個案，對爭議點進行討論。 (2). 也可以由不同的倫理角度出發，來思考該爭議點，例如：以病患的自主權出發、考慮病患的最佳利益、考慮社會經濟的整體利益…等。

醫法倫（IDP）寫作格式 Discussion：針對該特定個案，對爭議點進行討論。 (3). 告知內容須把握五項原則： 甲、診斷結果 乙、治療的方式與過程 丙、可能產生的合併症 丁、預後情況 戊、是否有其他治療方式的選擇

醫法倫（IDP）寫作格式 Planning：在經過討論後，針對該議題決定如何處理。

醫法倫（IDP）寫作格式 Issue：請家屬代理決定作氣管切管事宜。 Discussion： 主治醫師：由於病患的父親已中風，意識不清，且痰液無法自咳，故必須接受氣 20 切手術，以利於日後照顧。 家屬 A：我們不願意做氣切手術，不願意讓父親再接受任何的痛苦。 主治醫師：若不接受氣切手術，可能就要一直有氣管內管維持呼吸道通暢，而氣 管內管會有堵塞的危險，且換氣管內管時相當危險。 家屬 A：我再和我母親商量好了。 Plan：安排下次與病患之配偶與兒子晤談。

以英文記載病歷常見的錯誤

性別、所有格的錯誤 ** Do not just use male or female; write “man” or “woman”. 【例】：Patient is a 62 years old female, his chief complaint is abdominal pain. 建議：The Patient is a 62 years old woman, her chief complaint is abdominal pain. ＊有關主訴（chief complaint）的寫法： 1. The patient is a 62-year-old woman, and her chief complaint is abdominal pain. 2. A 12-year-old girl complained of abdominal pain. 3. A 7-year-old boy was admitted to the hospital because of abdominal pain. A 40-year-old man presented with abdominal pain. ** Do not just use male or female; write “man” or “woman”.

時態 (tense) 的錯誤 【例】：He had hypertension and still on three kinds of antihypertensive. 建議： He has hypertension and still on three kinds of antihypertensives. He has hypertension and is on three kinds of antihypertensives. He has hypertension and is on three kinds of antihypertensive medications. 【例】：Before he came to our clinic today, he had ever went to another two hospital clinics. 建議：Before he came to our clinic today, the patient had visited clinics at two other hospitals. 建議：Before he came to our clinic today, the patient had been to clinics at two other hospitals.

介系詞的錯誤 【例】：In last Saturday, his headache was suddenly got worse. 建議：Last Saturday, his headache suddenly got worse. 【例】：The patient had an acute process superimposed to his background conditions. 建議：The patient had an acute process superimposed on his background conditions. 【例】: A 45 year-old woman of mitral stenosis….. 建議 : A 45 year-old woman with mitral stenosis….

主詞的錯誤 建議： 【例】：Cancer was told 這是主詞弄亂了。 The patient was informed to have cancer. The patient was told to be having cancer. He was diagnosed to have cancer. He was told to have cancer.

單字、單詞的錯誤 【例】：Acception note 建議：沒有acception一字，應該是 acceptance note 或 on service note (相對的可寫off service note) 【例】：Progression note；Progressive note. 建議：應寫成 Progress note。 【例】 : Past history: Nil. 建議 : Nil is a Latin word; it means “nothing” or “Zero”. 應寫成 “Non-contributory”.

單字、單詞的錯誤(續) 【例】：Discharge diagnosis: R/O cancer. 建議: R/O (rule out) 是“須排除”、“應排除”之意， R/O cancer 可用於住院時的診斷。不過住院診斷工作 (work up) 之後，癌症的診斷應該是已經被ruled in 或 ruled out。如診斷仍未被確認，而癌症還是最有可能， 則應寫成Discharge diagnosis: probable cancer或 suspected cancer。 【例】：sepsis、septicemia、bacteremia的用法。 建議：有感染症狀時稱為sepsis (敗毒症)，再加上血液培養有細菌，則稱為septicemia (敗血症) 。只血液培養有細菌則稱為bacteremia (菌血症)。醫用英文翻譯成中文時，應該注意其原有的希臘文或拉丁文的字根意義。

錯誤使用 positive 或 negative 【例】：The biopsy was negative. The exercise test was positive. The ECG was negative. 檢驗結果不要用“positive”或“negative” 這些應該寫為： Laboratory tests (studies) gave normal results. Laboratory tests showed normal values. Laboratory data were normal (or within normal limits). The result of the biopsy was unremarkable. The exercise test was abnormal. The ECG revealed no abnormality.

Nothing particular (N.P)或non-made的誤用 在病歷書寫時應避免寫“無特殊之處”，應該寫出詢問出什麼，結果正常、或無發現；或是做了檢查，結果正常。故英文應用negative for, unremarkable, non-contributory等字詞。 【例】：The family history was nothing particular.應改為：The family history was unremarkable (or non-contributory). Non-made是說做了切片檢查，沒有發現不正常的（癌）細胞。但是，英文不這麼說。 【例】：The biopsy was non-made. The pathology was non-made. 應改為：The pathology did not reveal malignant cells.或是No malignant cells were found in the biopsy specimen.

贅語或俗語 常使用兩個名詞連在一起，或是為節省書寫將一些簡寫當作名詞或動詞。 肝硬化應該是cirrhosis，而常寫成liver cirrhosis或是cirrhosis of the liver. Cirrhosis本身就是肝硬化，因此不須加上liver。 seizure attack, 只需寫seizure，或epileptic fit。 a tumor mass，應寫為 a tumor, a mass (lesion)。 fever of 38°C應寫為 (fever with) a temperature of 38°C。 The patient was AAD (against advice discharge, 自動出院)，應寫為The patient was discharged AMA (against medical advice) 或 to be discharged AMA 或 discharge AMA。 The patient MBD (may be discharged ) today. 意思是“可以出院”，應寫為The patient is ready for discharge today.或to be discharged；discharge today；discharge tomorrow morning 或 discharge in AM 。

其他常見的不當使用語詞 Victim Victim翻譯是“受害者”，病人雖然受病痛，但是使用這個字不當。何況已經寫patient，不須再用victim。 【例】：The patient is a victim of type 1 DM diagnosed since 2 years ago. 應寫為：The patient was diagnosed as having type 1 DM two years ago. 【例】 : The patient is a victim of motor vehicle accident (MVA). 應寫為 : The patient had a MVA.

其他常見的不當使用語詞 Unfortunately 常見病歷寫〝Unfortunately, the patient had…..〞，這個意思是說病人的情況本來是穩定的，但是後來發生了某些症狀或是事件。病人生病本來就是不幸的事，不須再強調，不須以哀傷的語氣如unfortunately、sadly、miserably、unluckily等呈現在病歷。 【例】：Unfortunately, nausea, vomiting and abdominal pain developed since last night, and the patient was brought to ER for help. 應改為：The patient was well until last night when nausea, vomiting and abdominal pain developed, and he was brought to the ER.

其他常見的不當使用語詞 A test (or examination) was arranged (performed), which showed… 不須寫安排或者執行什麼檢查，直接寫出檢查發現什麼即可。 【例】：CT scan of the head was arranged (performed), which showed subdural hematoma over the left parietal area. 應改為：A CT scan of the head showed subdural hematoma over the left parietal area.

其他常見的不當使用語詞 Culture showed bacteria 細菌培養長出細菌不適用show或reveal，應該用yield 或 grow 【例】：The sputum culture showed Streptococcus pneumoniae infection. 應改為： The sputum culture yielded (grew) Sreptococcus pneumoniae. Bacterial culture was positive for Streptococcus pneumoniae.

其他常見的不當使用語詞 According to the statement of the patient 這似乎強調這份病歷是病人親口說的，其實病歷不是司法的筆錄，只要說是根據病人或誰陳述即可，或是直接說病人如何。 應改為： According to the patient, …. 或 The patient stated that she had epigastric discomfort 30 minutes after last dinner. According to the patient’s mother,

其他常見的不當使用語詞 During the period of admission 這是中式英語的另一例子，亦即“住院期間”。但是admission是由醫院進入病房的一個行為，因此沒有所謂period。應該寫為During the hospitalization或是During the hospital stay。

其他常見的不當使用語詞 A disease was diagnosed. The patient was diagnosed as a disease. 中文的意思是很簡單，“病人診斷什麼病”，但是英文不能寫為“疾病被診斷”；也不能寫為 “病人被診斷成（as a disease）什麼病”。 【例】：Colon cancer was diagnosed. 應改為：The patient was diagnosed as having colon cancer. 或是 A diagnosis of colon cancer was made.

其他常見的不當使用語詞 使用太多連接詞，使句子太長 The patient went to the hospital and was diagnosed of osteoarthritis, so medications were given and the pain decreased in severity, but she had to take the medicines regularly. 應改為：The patient went to the hospital, where a diagnosis of osteoarthritis was made. She took analgesics regularly with some relief of her pain.

其他常見的不當使用語詞 Irregular control, Regular medication 常看到病歷寫irregular control或irregular medication或regular medication。例如，The patient has hypertension for 10 years with irregular medications. 這也是中式英語，意思是說病人規則(按時)或不規則(不按時)服藥。先說regular medication並不能說病人一定是按時服藥，服一天藥休息一天，也是“規則“的。因此相對的“不規則“也顯得沒意義。不按時服藥可能是病人疏忽、不在意自己的病情、或是服藥發生不良反應。這些應該區分清楚，才能進一步對病人處置。 應該修改為： The patient has had hypertension for 10 years, but he did not take medicine as ordered. The patient has had hypertensive for 10 years, but he has not been taking medicine regularly.

其他常見的不當使用語詞 Ever Ever一字英漢字典翻譯成「曾經」，但其實是at anytime past or future, 有always constantly之意，不能依中文「曾經」的用法在英文句子中出現！ 【例】： The patient ever went to a hospital. 建議： The patient has been to a hospital. The patient did go to a hospital. The patient went to a hospital.

其他常見的不當使用語詞 【例】：The patient is anemia. Conscious: clear. 形容詞 【例】：The patient is anemia. Conscious: clear. 建議：The patient is anemic. 或 The patient has anemia. Consciousness: clear. 或 Consciousness: alert, 【例】：Mentality clear 建議：mentality是智力、悟性，通常病患並不做智力測驗，應該寫Consciousness (知覺、意識) clear。 名詞

其他常見的不當使用語詞 In vain 【例】 The patient went to an LMD for treatment but in vain. 建議： The patient went to an LMD for treatment, but the symptoms did not improve. (或 the treatment was not effective) 病人不是“去”醫師診所這件是徒然無功(迷路了)，〝in vain〞此字非專業用語。

其他常見的不當使用語詞 【例】：The patient developed abdominal pain and high fever. 建議：Abdominal pain and high fever developed. 因症狀不是病人使它發生。 【例】：Thank you for the consultation. 建議：Thank you for the referral. Thank you for the consultation request. 或簡單地 Thanks! 但不能寫Thank you for the consultation（這樣寫變成感謝自己的意見了）。 【例】：Dear Dr.；We sincerely request… 建議：會診單本來就是要求醫師來評估、建議，本來就是看得起被要求會診的醫師而發。因此 Dear Dr. ; We sincerely request…; your expertise…; 等等敬頌詞句被省略也應該不失禮。

英文病歷常用語句

病人或家人描述 陳述 Tell, state, claim, assert, describe, said 認為 Think, feel, believe, suspect 根據、聲稱 According to 根據所憶 To the best of one’s memory, as one’s recall 就其所知 To one’s knowledge, as far as one knows

Examples The patient stated (claimed, said) that he had abdominal pain just after meals. The patient suspected (thought) that he acquired his infection during a journey to the Mainland China one week ago. According to the patient’s son, he was noted disoriented in time about 2 weeks ago.

發現症狀或發病、檢查發現 症狀開始 Start, begin, appear, occur, develop 表現出 Manifest, exhibit 注意、發現 Note, notice, find, aware of, feel, complain of 遭受、遭遇 Suffer, experience (檢查)發現 Reveal, show, detect, disclose

Examples The patient began to have diarrhea 3 days ago. (Diarrhea started 3 days ago.) Initially the patient had poor appetite and nausea, and jaundice became manifested (appeared) 3 days later. A inguinal bulging mass was noted (found) during routine physical examination at school. The patient was noticed to have elevations of serum creatinine and uric acid at the annual medical checkup. The patient was suddenly suffered from a severe pain in the right upper quadrant of the abdomen. The patient experienced a gradual onset of pain around the lower back. A chest x-ray examination revealed (showed) an abnormal infiltration in the right upper lung.

就診、住院、出院、進行檢查或處置 就醫、求診 Call (get, send for) a doctor, seek medical advice, consult (see, visit) a doctor 入院 Admission to a hospital, be hospitalized (admitted), enter 出院 Be discharged, discharge, leave a hospital 回診、複診 Revisit, return visit, follow-up visit 進行檢查或處置 Undergo a test, do, take

Examples The patient sought medical advice for the swelling of his scrotum. He was admitted (hospitalized) because of chest discomfort and palpitation for one day. The patient visited 台中榮總 and was told to have colon cancer. A blood test was done (taken), and the result showed 50mg/dl of blood sugar. The patient underwent an emergent laparotomy and colon perforation was noted.

描述過去健康情形 健康狀況 Healthy, well, poor, ill 活力 Healthy, energetic, vigorous 健壯 Strong, robust 虛弱、生病 Weak, sick, ill, be afflicted with, be indisposed with 臥床 Be bedridden, be ill in bed, be confined to bed vigorous KK: [‘vigeres ] a. (形容詞 adjective) 1. 精力充沛的;壯健的 2. 強有力的 indispose vt. (及物動詞 transitive verb) 1. 使不願;使厭惡 2. 使不能;使不適合

Examples The patient had been in good health (had been well) until 2 weeks ago when she had severe chest pain, which occurred suddenly after paroxysmal cough. This 50 y/o man had enjoyed an excellent health until one month ago when he experienced occasional low abdominal pain. The patient has been bed-ridden (confined to bed) with paraplegia since the traffic accident happened to him one year ago. The patient was afflicted with diabetes for many years. Paroxysmal 陣發性的

發病時間、發病狀況 入院前 Before (prior to) admission (entry, this visit, hospitalization) 來診前 dated back to 3 days ago 住院中 During admission (hospitalization, hospital stay) 突然的 Suddenly, abruptly, an abrupt (acute, sudden) onset 徐徐的 Slowly, gradually, insidious, a gradual onset insidious KK: [in’sidi e s] a. (形容詞 adjective) 1. 陰險的;狡詐的;暗中為害的 2. (疾病等)不知不覺間加劇的;隱伏的

Examples Severe abdominal pain and high fever before admission (prior to this entry, hospitalization). During the three months before entry, the patient experienced progressive loss of weight and appetite. The onset of abdominal pain can be dated back to one week ago. During the admission, the patient was treated with antihypertensives. The patient experienced an abrupt onset of chest pain and dyspnea. He had swelling of the lower legs gradually (insidiously).

症狀描述 – 部位 發生在部位 Be located, be situated (in, at, over), be felt, be present 局限於 Be localized, be limited, be restricted, locally 全身性的 General, generalized, systemic, the whole body, over the entire body 蔓延至、放射至、轉移至 Spread, extend, reach to, diffuse, radiate, migrate, shift to

Examples The burning sensation was located (felt) in the left shoulder. The reddish skin was localized (limited) to the right instep and did not extent above the ankle. The sharp pain started in the right flank and radiated to the right hypochondrium and even down to the scrotum. The pain began in epigastric area and then shift to right lower quadrant of the abdomen. Instep 腳背

症狀描述 – 頻率 長期、慢性的 Long-term, long-standing, chronic, prolonged 短期、急性的 Short-term, brief, a short duration, acute 偶爾、發作幾次 Occasionally, on one occasion, an episode of, scanty, paroxysmal 持續的、時常的 Continuously, constantly, persistent, frequently last 一時性、間隔的 Temporary, transient, fleeting, intermittent off and on, fluctuating

Examples Tarry stool persisted over the next five days. For the past two weeks, the patient has had several paroxysmal dyspnea, which usually occurred at night and lasted for about 15 minutes. Constipation and diarrhea came alternately (alternative constipation and diarrhea). The blood-tinged stool was noticed at least on two occasions.

症狀描述 – 嚴重度 輕度 中度 重度 Mild, slight, a touch of Moderate, proper Severe, intense, violent, marked 輕症 A slight illness, a minor (mild) injury (attack) 重症 A serious illness, seriously (gravely, critically) ill, severely (badly) injured, in a critical condition 痛的描述 Sharp; vague; crampy; stinging; tingle vague KK: [vag ] a. (形容詞 adjective) 2. (想法等)不明確的;曖昧的,含糊的 3. 無表情的 4. (在否定句中用最高級)少許的[B] Stinging a. (形容詞 adjective) 1. 刺般的;激烈的 2. 尖酸的;刺痛的 Tingle vi. (不及物動詞 intransitive verb) 1. 感到刺痛;感到臉紅[(+with)] His cheek tingled from the slap she had given him. 他的面頰因挨了她一記耳光而感到刺痛。 2. 震顫;激動[(+with)] She was tingling with excitement. 她激動不已。 3. 發出叮叮聲;發出鈴鈴聲;(耳等)鳴響 My ears often tingle. 我常常耳鳴。 vt. (及物動詞 transitive verb) 1. 使感刺痛;使激動 2. 使發叮叮聲;使發出鈴鈴聲 n. (名詞 noun)[S] 1. 刺痛;震顫;激動 The cold caused a tingle in my fingers. 嚴寒使我的手指有刺痛感。 She feels a tingle of excitement. 2. 叮叮聲;鈴鈴聲;(耳等的)鳴響

Examples The epigastric pain gradually increased in severity. The chest pain, localized mostly over the left lateral chest, decreased in severity or was minimal when breath was held, but was aggravated by inspiration. The patient remained gravely ill after cholecystectomy, although his jaundice and liver function were not deteriorated. The patient suffered from vague (cramp) abdominal pain for one week.

症狀描述 – 量化及形容 量 A little, scantly, plenty of, a large (small) amount, gain (loss) weight, bulky 數、次數 A few, small in number, numerous, a large number of, increase (decrease) in number 大小 Be the size of, sized of, diminish (decrease; increase) in size (length, width) 形狀、顏色 In shape, shaped, be tinged (tinted) with tinge KK: [ ] DJ: [ ]   n. (名詞 noun) 1. (較淡的)色調,色彩[C][S1][(+of)] Her hair has a tinge of red. 她的頭髮帶著一點紅色。 2. 些許味道(或氣息);一絲痕跡(或性質)[S][(+of)] The music had a tinge of sadness. 這音樂帶有一絲悲傷。 vt. (及物動詞 transitive verb)[H][(+with)] 1. (輕淡地)給...著色,染 His black hair was tinged with gray. 他的黑頭髮帶著一點灰白。 2. 使帶有...氣息(或痕跡等) Mary's admiration for Jane is tinged with jealousy. 瑪麗對珍又羨又妒。 Her admiration for him was tinged with jealousy. 她對他的欽佩帶有一點妒忌。 tinted KK: [ ] DJ: [ ]   a. (形容詞 adjective) 1. (用作定語)(玻璃等)著色的

Examples The patient had intermittent cough for more than 20 years, and began to have a small amount of blood-tinged sputum in recent three months. A hen egg-sized lump has been noted on the abdominal wall without change in size or shape for the past ten years. The patient loss his weight from 70 kg to 60 kg within 2 months. Numerous pinhead-sized papules initially occurred over the chest, increased rapidly in number and spread to the neck and face.

症狀描述 – 症狀的誘因 誘發、引起、影響 Trigger, cause, precipitate, induce, bring about, provoke, influence, affect 前因 Precede, antecedent 傾向 Tend to, be apt to, have a tendency to

Examples The patient cannot recall any precipitating (provoking) factor of the attack. The chest pain was induced by walking for about 10 minutes and disappeared after taking a rest. The cramping ache was present constantly in the lower abdomen, unaffected (not influenced) by meals or bowel movement. The patient had a tendency toward cold sweating and dizziness before lunch, which could be relieved by taking a snack.

症狀描述 – 伴隨或相關症狀 伴隨 With, along with, concurrently, coincide with, accompany, simultaneously 合併 Be accompanied by, be complicated with (by), concur 續發 Following, be followed by, succeed, ensue 相關、有關連 Be related to, be associated with, have nothing to do with ensue KK: [ en’su ] vi. (不及物動詞 intransitive verb)【書】 1. 接著發生;接踵而來 2. (因...而)產生[(+from)]

Examples Concurrently, the patient had abdominal pain and diarrhea, in addition to vomiting. Epigastric pain persisted and was unrelated to meals. The chest pain was closely related to (associated with) position, movement, and swelling. The cough was followed by dyspnea and fainting attack few minutes later. The fracture of the left femur was complicated with pulmonary embolism.

症狀描述 – 姿勢或活動的相關症狀 運動 On exertion, on exercise 排尿 On urination, when voiding 仰臥、平躺 A recumbent position, a lying position, in a supine position 俯臥 In prone position, in a ventral decubitus 側臥 On (right or left) decubitus 蹲 On squatting 彎腰 In a leaning (stooping, reclining, stooping) position 爬樓梯 Climbing stairs 受限制 Limit, restrict, confine 有困難 Trouble, difficult 受干擾 Prevent, disturb, interrupt 困擾於 Annoy, bother, trouble

Examples The patient often felt dizzy when rose suddenly from recumbent or sitting position. The backache was mild on standing erect, and could be partially relieved by bending forward. The pain could be significantly decreased by lying on his right decubitus.

症狀描述 – 病情變化 病況變好、緩解、減輕 Progressing favorable, doing well, make a favorable progress, relief, remission, palliation, lessen, diminish, subside, improve, reduce, got better, decline 病況轉壞、惡化 Aggravated, worsen, getting worse, progressively worsening, an unfavorable progress, degenerated 復發 Relapse, recurrence, flare-up, recrudescence 接受治療 Receive (take) treatment, be under treatment, drugs be prescribed

Examples After the operation, the patient made a favorable progress. The pain of ankle was relieved promptly after the patient took the doctor’s prescription. In spite of intensive management of his heart failure, the patient’s consciousness got worse and was aggravated by pneumonia. The leg edema subsided gradually after the patient took diuretics.