【2017年整理】1、 抗生素医嘱.docxVIP

1、 抗生素医嘱[Antibiotic order] ·Prophylaxis [预防性用药] Duration of oder[用药时间] 24hr Procedure[操作，手术] ·Empiric theraphy [经验性治疗] Suspected site and organism[怀疑感染的部位和致病菌] 72hr Cultures ordered[是否做培养] ·Documented infection[明确感染] Site and organism[部位和致病菌] 5days ·Other[其他] Explanation required [解释理由] 24hr ·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] ·Acitivity [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] 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] Heart rate[心率] Heart rhythm[心律] Heart Border[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] 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]: *Hb8.5 [血色素8.5] *20% blood volume lost [20%血容量丢失] *c