病历文书中常用基本用语的英文翻译,快快收藏哦！
1、抗生素医嘱[Antibioticorder]
•Prophylaxis[预防性用药]
Durationoforder[用药时间]24hr
Procedure[操作，手术]
•Empirictherapy[经验性治疗]
Suspectedsiteandorganism[怀疑感染的部位和致病菌]72hr
Culturesordered[是否做培养]
•Documentedinfection[明确感染]
Siteandorganism[部位和致病菌]5days
•Other[其它]
Explanationrequired[解释理由]24hr
•Antibioticallergies[何种抗生素过敏]
Noknownallergy[无已知的过敏]
•Drug+dose+Route+frequency[药名+剂量+途径+次数]
•Admit/transferto[收入或转入]
•Resident[住院医师]Atting[主治医师]
•Condition[病情]
•Diagnosis[诊断]
•Diet[饮食]
•Activity[活动]
•Vitalsigns[测生命体征]
•I/O[记进出量]
•Allergies[过敏]
3、住院病历[casehistory]
•Identification[病人一般情况]
Name[性名]
Sex[性别]
Age[年龄]
Marriage[婚姻]
PersontonotifyandphoneNo.[联系人及电话]
Race[民族]
[身份证]
Admissiondate[入院日期]
Sourceofhistory[病史提供者]
Reliabilityofhistory[可靠程度]
MedicalrecordNo[病历号]
BusinessphoneNo.[工作单位电话]
HomeaddressandphoneNo.[家庭住地及电话]
•Chiefcomplaint[主诉]
•Historyofpresentillness[现病史]
•PastHistory[过去史]
Surgical[外科]
Medical[内科]
Medications[用药]
Allergies[过敏史]
SocialHistory[社会史]
Habits[个人习惯]
Smoking[吸烟]
FamilyHistory[家族史]
Ob/GynHistory[婚姻/生育史]
Alcoholuse[喝酒]
•ReviewofAystems[系统回顾]
General[概况]
Eyes,Ears,Noseandthroat[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]
ocrinology[内分泌系统]
Lymphatic/Hematologic[淋巴系统/血液系统]
•PhysicalExam[体检]
VitalSigns[生命体征]
P[脉博]
Bp[血压]
R[呼吸]
T[温度]
Height[身高]
Weight[体重]
General[概况]
HEENT[五官]
Neck[颈部]
Back/Chest[背部/胸部]
Breast[乳房]
Heart[心脏]
Heartrate[心率]
Heartrhythm[心律]
HeartBorder[心界]
Murmur[杂音]
Abdomen[腹部]
Liver[肝]
Spleen[脾]
Rectal[直肠]
Genitalia[生殖系统]
Extremities[四肢]
Neurology[神经系统]
cranialnerves[颅神经]
sensation[感觉]
Motor[运动]
*[专科情况]
*RadiographicFindings[放射]
*LaboratoryFindings[化验]
*Assessment[初步诊断与诊断依据]
*Summary[病史小结]
*TreatmentPlan[治疗计划]
4、输血申请单[Bloodbankrequisitionform]
(1)reasonforinfusion[输血原因]
▲红细胞[packedredcells,wshedRBCs]:
*[血色素8.5]
*20%bloodvolumelost[20%血容量丢失]
*cardio-pulmonarybypasswithanticipatedHb8[心肺分流术伴预计血色素8]
*chemotherapyorsurgerywithHb10[血色素10的化疗或手术者]
▲全血[wholeblood]:
massiveon-goingbloodloss[大量出血]
▲血小板[platelets]:
*massivebloodtransfusion10units[输血10单位以上者]
*plateletcount50×103/μlwithactivebleedingorsurgery[血小板5万伴活动性出血或手术者]
*Cardio-pulmonarybypassuithpl100×103/μlwithoctivebleeding[心肺分流术伴血小板10万，活动性出血者]
*Plateletcount20×103/μl[血板2万]
▲新鲜冰冻血浆[freshfrozenplasma]:
*documentedabnormalPTorPTTwithbleedingorSurgery[PT、PTT异常的出血或手术病人]
*specificclottingfactordeficiencieswithbleeding/surgerg[特殊凝血因子缺乏的出血/手术者]
*bloodtransfusion15units[输血15个单位]
*warfarinorantifibrinolytictherapywithbleeding[华法令或溶栓治疗后出血]
*DIC[血管内弥漫性凝血]
*AntithrombinIIIdficiency[凝血酶III缺乏]
(2)输血要求[requestforbloodcomponents]
*patientbloodgroup[血型]
*Hasthepatienthadtransfusionorpregnancyinthepast3months?[近3个月，病人是否输过血或怀孕过？]
*Typeandcrossmatch[血型和血交叉]
*Unitsorml[单位或毫升]
5、出院小结[dischargesummary]
PatientName[病人姓名]
MedicalRecordNo.[病历号]
AttingPhysician[主治医生]
DateofAdmission[入院日期]
DateofDischarge[出院日期]
PrincipalDiagnosis[主要诊断]
SecondaryDiagnosis[次要诊断]
Complications[并发症]
Operation[手术名称]
ReasonforAdmission[入院理由]
PhysicalFindings[阳性体征]
Lab/X-rayFindings[化验及放射报告]
HospitalCourse[住院诊治经过]
Condition[出院状况]
Disposition[出院去向]
Medications[出院用药]
Prognosis[预后]
SpecialInstructiontothePatient(diet,physicalactivity)[出院指导（饮食，活动量）]
Follow-upCare[随随访]
•Patientname[病人姓名]
•race[种族]
•address[地址]
•religion[宗教]
•medicalservice[科别]
•admit(discharge)date[入院（出院）日期]
•Lengthofstay[住院天数]
•guarantorname[担保人姓名]
•nextofkinorpersontonotify[需通知的亲属姓名]
•relationtopatient[与病人关系]
•previousadmitdate[上次住院日期]
•admittingphysician[入院医生]
•attingphysician[主治医生]
•admittingdiagnosis[入院诊断]
•final(principal)diagnosis[最终（主要）诊断]
•secondarydiagnosis[次要诊断]
•adversereactions(complications)[副作用（合并症）]
•incisiontype[切口类型]
•healingcourse[愈合等级]
•operative(non-operative)procedures[手术（非手术）操作]
•nosocomialinfection[院内感染]
•consultants[会诊]
•[抢救次数]
•[成功次数]
•Diagnosisqualitativeanalysis[诊断质量]
[门诊入院与出院诊断符合率]
ClinicalandpathologicalDxconcur[临床与病理诊断符合率]
Pre-andpost-operativeDxconcur[术前术后诊断符合率]
•Dxdeterminedwithin24hours(3days)afteradmission[入院后24小时（3天）内确诊]
•Dischargestatus[出院状况]
recovered[治愈]
improved[好转]
notimproved[未愈]
died[死亡]
•Dispositon[去向]
home[家]
againstmedicalad[自动出院]
autosy[尸检]
transferredto[转院到]
