病歷寫作 方川尹醫師 Dec. 26, 2010

Assessment/plan – admission note Colon cancer Colonoscopy, double contrast of colon, CT scan ,check HGb, CEA Pre-op prepare and colon prepare Radical right hemicolectomy Post-op care Diet , activity

Assessment and Plan 1. diagnostic Abdominal CT scan, pelvic MRI, CEA, Ca-199 2. therapeutic Pre-op colon prepare with kleap 1 PG and ducolax 3# st, cleansing enema Surgical intervetnion with R’t hemicolectomy Post-op care: NPO, IVF with tatai No3 1000cc+No 5 1000cc ivd qd, antibiotics

With cefazolin 1000mg q8h + GM 80mg q12h + flagyl ( metronidazole) 500mg q8h ivd 3. educational: On soft diet for 1 weeks Avoid heavy activity

Problems list #1 Ascending colon cancer #2 post-op wound pain #3 hyperglycemia (hypertension) #4 anastomotic leakage

Progress Note Problem-oriented medical record ( POMR)是未來評鑑的趨勢. 可將各個Problem以S.O.A.P.方式記載; 但不必每天討論每個Problem. 一定要記載已接受的治療,主治醫師對病情的進展及醫療效果的評估.

病歷記錄最好採Problem-Oriented 方式就病人不 同的問題逐一分析，各問題之分析宜採S.O.A.P 記錄： S (Subjective Data) ：自覺徵候，包括病人主 訴、症狀、及發病時間、現在病史、過去病史及 個人史。 O (Objective Data) ：檢查發現，包括診察發現 及各種檢查報告。 A (Assessment) ：（診斷與病情評估），包括診 斷(Diagnosis) 、臆斷(Impression) 、病況或症 狀(候)評估 P (Plan) ：（治療計劃），包括各種處置、醫令 或處方

SOAP S: Subjective 主觀陳述 O: Objective 客觀發現 A: Assessment 評估 P: Plans 計畫

S O Assessment P 1.Sepsis, suspected Pneumonia 2.DM type 2, out of control 3.History of cervical ca, s/p total hysterectomy 4.Diarrhea, cause to be determined

S O Assessment/Plan 1.Sepsis, suspected pneumonia: Third day of cefuroxime 1.5 gm, q8h. Clearly improving. To continue the same Rx.For 6-7 days. 2.DM type 2: Sugar level is under control with ... 3.Hx/O cervical Ca: checked by Gyne. No signs of recurrence. 4. Diarrhea has stopped 3 days after admission. Stool culture (-), cause unknown; related to the pneumonia? Antibiotics?

Assessment 錯誤的寫法 每天只是重複寫下Admission note 之Impression而無評估

X: Sepsis, R/O pneumonia. O: Sepsis, suspect pneumonia: Pneumonia confirmed by chest X-rays. Third day of cefuroxime 1.5 gm IV q8h. WBC decreased. Clearly improving with less cough. To continue the same treatment for one week.

X: Non-insulin Dependent Diabetes Mellitus. O: Non-Insulin Dependent Diabetes Mellitus: Sugar level is under control with Diamicron 1# P.O. bid and Glucophage 1# P.O. bid

Procedure note簡易版 Date: Indication: Procedure: Complication: Result: Plan:

例 特殊檢查 -Date: 10. 18. 2008. 10:10 AM -Item: UGI series -Indication: bilious vomitus, abd. distension, suspected intestinal obstruction -Result: volvulus -Plan: consult surgeon for evaluation of the possible surgical intervention

5. On/Off-Service/Transfer Note 清楚交代治療情形、後續計畫、及特殊注意事項。 隔月交班要寫on/off-service note。 Transfer note：同一科部：普通病房互轉或普通病房與ICU互轉。 只要”轉”就得寫，不論轉人(R, VS)或病房(ICU)。

可改成這樣 99-11-24 abdominal CT scan: upper rectal cancer with regional lymphadenopathy and liver metastasis (S6-7), cT3N1bM1a, stage IV no urinary bladder and uterine invasion

常見的錯誤

病歷書寫常見缺點 病歷首頁 Final diagnosis與Discharge summary不一致 無血型及過敏史之記載 住院病歷封面 缺少醫師簽章 紀錄不全 診斷用英文縮寫 -------TJCHA (CWL)

病歷書寫常見缺點 TPR sheet 看不出主要治療藥物之期程(duration), 開刀日期, 及各種重要突發事件(如:昏迷,seizure等)

病歷書寫常見缺點 Admission Note: Chief Complaint: 未註明duration, mode of onset Present Illness: 常見以流水帳方式記錄,看不出實際病程變化; 缺少目前用要資料(current medications) Past History: 內容過份簡單,遺漏重要病史,如手術或其他嚴重疾病

病歷書寫常見缺點 Admission Note Review of systems: 多用制式電子檔,與病人情況不符. Physical examination: Vital signs不全,只填寫制式電子檔,未深入對病人實際問題評估;未做的檢查往往以正常或-表示 檢查結果只填寫(+)或(-),無法判讀 Positive findings沒有說明或圖示 沒有記載endo /NG tube,手術疤痕或傷口

病歷書寫常見缺點 Admission Note Diagnosis: Plan:只寫用藥,未用文字敘述其他診療計畫 常以R/O表示. 只有症狀,未寫diagnostic probabilities Plan:只寫用藥,未用文字敘述其他診療計畫 書寫者為實習醫學生或住院醫師時,缺少主治醫師之訂正及簽章

病歷書寫常見缺點 Progress Note: 書寫內容都以電子檔複製,千篇一率,看不見病程進展,與病人實況有出入. 對各種檢查或處置,沒有說明其理由或必要性,沒有紀錄結果或對診斷和治療之影響. 沒有對會診結果做紀錄或表示意見

病歷書寫常見缺點 Discharge Summary: 出院診斷未包括所有的主診斷及次診斷 病史複製自Admission note,未加摘述;未書寫住院中之重要病程變化. 無出院時情況之評估及出院指示 Laboratory data 以電腦檔自動下載,未做摘要重點敘述.

病歷書寫常見缺點 冗長的紀錄(大多是制式電子檔),看不出重點,由現病史,過去病史及身體檢查,實驗室檢查的紀錄中,看不出與診斷的關連性及前因後果. 建議: 標示出重點資料(highlight)或做重點摘要,呈現思考邏輯.

MIT 醫用英文 ? 誤用 適當用法 MIT = Made in Taiwan 誤用 適當用法 =============================================================== "coming morning“ "in a.m." or "tomorrow morning" - 英文無此用法 "MBD (may be discharged)“ "discharge" - 誰來決定 ? "easy looking" / "acute ill looking" "in no distress" or "appears well" - 怪異之表達 "(appears) acutely ill" "Acception Note" "Acceptance Note" - 無 "acception" 此英文字 "victim" (of diabetes, hypertension etc.) 只用於災難或犯罪行為，如 " rape victim" - 疾病無 victim “unfortunately” 敘述客觀事實 - 敘述病情不容主觀評論 MIT = Made in Taiwan

X: Physical examination was normal ( or negative ). O: Physical examination revealed noabnormalities. O: Results of physical examination were normal. O: No abnormalities were disclosed ( found, noted ) on physical examination.

X: Laboratory was negative. The biopsywas negative X: Laboratory was negative. The biopsywas negative. The ECG was negative. O: Laboratory tests gave normal results. O: Laboratory tests showed normal values. O: Latoratory data were normal. O: The results of the biopsy was negative.

R/O ( rule out ) 的意思是“排除”. 因此前提必須是有一個相對的診斷,然後須排除什麼疾病或診斷. X: Fever, R/O pneumonia. 原本意思是病人發燒,肺炎是最有可能的診斷, 但讀起來卻是:排除肺炎. O: 應該寫成: Fever, suspect pneumonia; R/O viral infection ( or drug fever )

X: Cancer was told. O: He was told to be having cancer. Cancer was suspected or diagnosed. X: The patient went to an LMD in vain. 病人並非去醫師診所迷路 O: The patient went to an LMD and the treatment was not effective ( or the symptoms did not improve )(or without benefit).

X: The patient ever went to a hospital. O: The patient has been to a hospital. The patient did go to a hospital. X: Acception note. O: Acceptance note. On service note. X: Progression note. Progressive note. O: Progress note.

X: conscious clear. O: Consciousness: alert. X: Cancer was impressed. O: Cancer was suspected. X: The patient is anemia. O: The patient is anemic. The patient has anemia.

X: The patient is a victim of motor vehicle accident ( MVA ). O: The patient had an MVA. X: MBD ( may be discharged ). O: discharge; discharge in AM. X: AAD O: discharge against medical advice ( AMA)

X: After the patient was admission O: After the patient was admitted X: Unfortunately, abdominal pain and high fever developed O: Abdominal pain and high fever developed. X: He had cough since 3 days ago. O: He has had cough for 3 days. He has been coughing since 3 days ago.

謝謝聆聽！ The End!