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Overview Admission Note

Overview Admission Note. 入院录写作概述. 杨明山. Medical Literature. Medical Record. Classification of Medical Writing. Admission Note. MIAs abstract IMRAD paper Systematic Review. General Medical Record (History) Admission Note Daily Record Discharge Note.

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Overview Admission Note

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  1. Overview Admission Note 入院录写作概述 杨明山

  2. Medical Literature Medical Record Classification of Medical Writing Admission Note

  3. MIAs abstract IMRAD paper Systematic Review General Medical Record (History) Admission Note Daily Record Discharge Note Classification of Medical Writing Admission Note

  4. Clinical Record POMR Problem-oriented Medical Record

  5. Lawrence Weed. MD. • 1947: Columbia University • ？: Yale University School of Medicine • 1964: “Medical records, patient care, and medical education”

  6. Medical Writing Series 4.20method (Admission Note)

  7. 入院录 廿句写作法

  8. Chief Complaint Section One

  9. Chief Complaint Section One Only 1 sentence

  10. 第1句 – 主诉- 写作分析

  11. 第1句 – 介词妙用 – 主诉 • A 25 year-old ladywas admitted to1 this hospital on2May 11, 2003 because of3fever and cough with4chill for5three days.

  12. Histories Section Two

  13. Histories Section Two Current History

  14. 第2句 – 起病写作分析

  15. 第3句 – 演变写作分析

  16. 第4句 – 经治写作分析

  17. 第4句 - 其他表达 • home medication • customary medication • outpatient medications • No treatment

  18. 第4句 – 经治效果表达

  19. 第5句 – 状态写作分析 – 无特殊

  20. 现病史写作关键：time adverbial • 点：Since the initial diagnosis, ……. • 时刻：……. at approximately 5 a.m. • 小时：Several hours after these symptoms, ….. • 半天：That afternoon ……. • 天：On the fifth hospital day …….. • 天：On hospital day 5 ……. • 周：Over the next week ……. • 月：Two months prior to admission, ……. • 年：One year ago …….

  21. Histories Section Two Other Histories

  22. 第6句 – 过去病史写作分析

  23. Family, Personal, Ob/Gyn (Childbearing) H. • Customary medications were xx. • His only medication was xx for xx. • P did not smoke and rarely consumed alcohol. • P had a x-pack-year smoking history • There was a (no) family history of xx. • Parents are alive and well. • P died of x at the age of

  24. 第7句 – 家族史写作分析

  25. Examinations Section Three

  26. 第8句 – 生命体征写作分析

  27. 第9句 – 望诊写作分析

  28. 部位: Vigorous small intestinal peristalsis can be seen in the center of the abdomen. 时间: Symmetrical distension is seen when intra-abdominal content is increased. 特征: An enlarged uterus was seen as a central rounded suprapubic swelling. 病理: Paralytic ileus is seen in patients after abdominal surgery. 第9句 – 望诊写作要求

  29. 第10句 – 叩诊听诊写作分析

  30. 第10句 – 触诊表达 • To be palpated；To be felt • 部位：Small masses (nodules) are felt near the uterus or in the cul-de-sac. • 时间:No fibroids are felt during the bimanual pelvic or rectal exams. • 特征: His neurologic exam demonstrated mild generalized hypotonia

  31. 第10句 – 叩诊表达 • To be heard；tap, strike, flick, Percuss • 部位: These sounds are heard only over the bronchi and trachea. • 时间: Friction was heard in both inspiration and expiration. • 特征:The cancerous area was felt as a hard, irregular nodule. • 病理: It is heard in bronchiectatic cavities or pneumothorax.

  32. 第10句 – 听诊表达 • location： A soft, high-pitched, holosystolic blowing murmur is heard in the mitral area. • time： A murmur can be heard during the diastole. • feature His lungs were clear to auscultation. • other An aortic murmur is heard with the patient sitting forward in full expiration.

  33. 第10句四诊句型-介词短语 • On physical examination, … • A tapping apex beat may be apparent on inspection. (最多） • Ill-defined nodule margins by palpation • The nodule was evident at palpation

  34. 第11句 – 辅助检查写作分析

  35. Imaging, Ultrasound and Others • Doppler studies revealed normal blood flow to bothovaries. • A friablelesion 15 to 20 mm in diameterwas identified very low in the rectum. • During a digital rectal examination, a mobile, softmass was foundlow in the left rectum.

  36. ⒂Imaging, Ultrasound and Others • Pattern • Exam showed … • The liver was shown to be enlarged… • The heart murmur was heard … • 检查项目作主语：主动态 • 阳性体征作主语：被动态 • 人的器官作主语：被动态

  37. 第12句 – 实验写作分析

  38. 第12句 – lab 表达 - Same • Item was normal. • Item waspositive • Item wasnegative • Item wasnumber • A serologic test for antibody to Helicobacter pylori was positive. • The urine was positive for ketones (++). • The uterine volume appeared normal. • A stool specimen was negative for occult blood.

  39. 第13句 – 采样写作分析

  40. 第14句 – 写作分析 – 回报

  41. Universal There-be 万能句 • Current History: On the sixth day, there was an episode of bradycardia and vomiting • Previous Hisroty: There was no history of sexually transmitted disease. • Inspection There was swelling in one rear “ankle” as well. • Palpation There was a large hard irregular mass in the abdomen. • Percusion There was a minimal corneal reflex in the left eye. • Ausculation There were scattered rales and rhonchi all over the lung fields.

  42. Approach Section Four

  43. 第15句 – 正文 – 诊断 • Our impression of the case would be severe acute respiratory syndrome.

  44. 第15句 – 诊断写作分析

  45. 第16句 – 治疗写作分析

  46. Xx given Xx prescribed Xx instituted Xx was administered administered taken orally injected infused intravenously, intramuscularly, by TPN 第16句 – 治疗其他表达

  47. 第17句 – 写作分析

  48. 第18句 – 当前问题写作分析

  49. 第19句 – 写作分析

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