医学英语翻译与写作：Medical English Writing(5) writingthe case history

1、Medical English WritingShandong UniversityMay, 2014Medical English Writing (5)Writing the medical recordsMay, 2014 病例 病历caseMedical recordCase historyMedical clerkingClinical chartDistinguish the following terms:medical record case reportclinical reportclinical recordcase historymedical clerking dis

2、charge summaryoperative reportlaboratory report admission assessmentadmission noteprogressive note nursing noteconsultation requisition noteconsultation notepre-anesthetic noteanesthesia record discharge note医疗记录；病历，病案病例报告临床报告临床记录病历病历；病案（记录）出院总结手术报告化验报告；实验室报告入院评估入院记录病程记录护理记录会诊申请记录会诊记录麻醉前纪录麻醉记录出院记录Wh

3、at Is A Medical Record?A medical record is information about the health of an identifiable individual recorded by a doctor or other healthcare professionals. It should contain sufficient information to “identify the patient, support the diagnosis, justify the treatment, document the course and resul

4、ts, and promote continuity of care among healthcare providers”. Case ReportA case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. It is written based on the medical records. Case reports usually describe an unusual or novel occurrence

5、. Generally a case report is less than 2,000 words.medical recordcase report clinical report clinical record case history (medical clerking)discharge summaryoperative reportlaboratory reports admission assessmentadmission noteprogressive notenursing noteconsultation requisition noteconsultation note

6、pre-anesthetic noteanesthesia record discharge noteMost case reports are on one of the topics:Unexpected or unusual presentations of a diseaseUnreported or unusual side effects or adverse interactions involving medications New associations or variations in disease processes Presentations, diagnoses

7、and/or management of new and emerging diseases An unexpected association between diseases or symptomsAn unexpected event in the course of observing or treating a patient Findings that shed new light on the possible pathogenesis of a disease or an adverse effect Publishing case reports Many internati

8、onal journals will publish case reports, however there are a few that are devoted to publishing case reports alone. Journal of Medical Case Reports, Case Reports in Medicine, and Cases Journal are three such journals, publishing open access peer reviewed case reports in all areas of medicine. BMJ ca

9、se reports is an online, peer-reviewed journal publishing cases in all disciplines. The Journal of Radiology Case Reports is a journal focusing on medical imaging. Journal Of Surgical Case Reports is a journal that considers case reports in the field of surgery. Structure of a case reportTitleIntrod

10、uction or AbstractCase Presentation or Diagnosis and TreatmentDiscussionReferenceCase HistoryA case history is a complete record of the symptoms, signs, findings of check-up, personal and social factors, diagnosis and treatment of a case.It is not only the important foundation of diagnosing and trea

11、ting diseases of a patient, but the information for medical research, and the evidence with legal validity.Basic RequirementsNotes should be written during the consultation or immediately afterwards, as soon as possible after the event has occurred. True and complete record, accurate and brief prese

12、ntation All the words shall be in the same ink, neat and clear. They shall be free from any alterations.Basic RequirementsDate (Year, Month And Day) exactly on each note, even hour and minute for an emergency treatment. The time should be recorded as 24-hour time, e.g. 14-02-2009, 14:05(BrE) or 02-1

13、4-2009, 14:05(AmE)Fill out each item of the tables, with the name, admission number, department, bed No. on each page.Symptoms, signs, diseases and organs are stated with medical terms.Items of a case historyGeneral DataChief Complaint (CC )History of Present Illness ( HPI/PI)Past (Medical ) History

14、 (PH)Family History (FH)Personal History (Per. H)/Social History (SH)Drug historyAllergiesSystems Review/Inquiry Physical Examination (PE)Laboratory ExaminationDiagnosis/Impression (Imp.)/SummaryHospital courseDischarge InstructionsDischarge MedicationGeneral Data Name 姓名Sex 性别Age 年龄Occupation 职业Dat

15、e of birth 出生日期Marriage （Marital status） 婚姻,婚姻状况Race 民族Place of birth (Birth place) 籍贯Identification No. (code of ID card No.) 身份证号码Department of work and TEL. No. (Unit and Business phone No.) 工作单位及电话General DataHome address and phone No. 家庭住址及电话Post code 邮政编码Person to notify (Correspondent) and ph

16、one No.联系人及电话Source (Complainer; offerer; supplier; provider) of history 病史陈述者Reliability of history 病史可靠程度Medical security (Type of payment)医疗费用Type of admission (Patient condition)住院类别（入院时病情）Medical record No. 病历号Clinic diagnosis 门诊诊断Date of admission (admission date) 入院日期Date of record 记录日期Reliab

17、ility:Reliable Not entirelyNot clearly definedConfused and uncertainUnobtainable可靠不完全可靠不够准确混乱不清无法获得General Data（Introduction） Sample:The patient, a thirty-five-year-old Caucasian female, housewife, was first seen in the office with a chief complaint of upper respiratory infection of 3 days duration.

18、Chief ComplaintA detailed objective account of the patients central problems which have been already identifiedPut details about the problem and related symptoms in a chronological orderThe duration of the chief complaint should be noted, for example “chest pain for 1 hour”. History of Present Illne

19、ssthe most important structural element of the medical history Detailed description of the “chief complaint”, or a chronological history and sequence of the chief complaint. What circumstances precipitated it，for example：climbing stairs, emotional upset such as anger, or sexual intercourse. What cir

20、cumstances relieve it: e.g. resting for a few minutes History of Present IllnessAttack/onsetLocationNature, feature, severityFrequencyRelationDevelopmentDiagnoses and treatmentPresent status起病症状所在部位症状的性质、特征、程度症状出现频率症状间关系病情的发展治疗经过病人现有体质Past HistoryPrevious state of healthPrevious illnessesVaccination

21、 and infectious diseasesAllergy to drugs or other substances过去一般健康状况过去所患疾病预防接种与传染病对药物及其他物质的过敏有无药物（食物）过敏史 past history of allergy to drugs (food )有无青霉素过敏史 allergic history of penicillin有无肺结核接触史contact history of lung tuberculosis外伤史trauma history预防接种史history of preventive inoculation健康状况佳（差）health st

22、ate was good (bad)既往体健be well (healthy) before 2000年6月因急性阑尾切除术Appendectomy was done in June, 2000 due to acute appendicitis否认既往心、肺疾病史deny any history of prior heart and lung disease10岁时（20年前）曾患过suffered from at age 10(20 years ago)易患be liable (subject, apt) to不详not in detail (not quite clear)Family

23、History (FH)mainly parents, siblings, children, and spouse involved, grandparents if necessarythe health status and illnesses of the family members: be living and well; hereditary/genetic diseases; infectious diseases; time and cause of death mental handicap, dementia should be paid attention toPers

24、onal HistoryLife style and habitsOccupation and working conditionsTravellingMarriage and Child-bearingMenstruation生活方式及嗜好职业和工作环境外出旅游婚姻和生育月经Systems ReviewThis section is to consult and record the past conditions of each system.This section is too often omitted.Noncontributory(无可记述) and See Present（Pa

25、st）Illness （见现病史/既往史）can be used in some itemsPhysical Examination To find and record related signs of the patient by inspection, auscultation, palpation and percussion for making correct diagnosisMainly include: general items (temperature, pulse, respiration, blood pressure, heart rate, physical de

26、velopment, nutrition appearance and consciousness, skin and lymph), head and neck, chest and abdomen, nervous system, skeleton and muscle, urogenital system and othersWhen recording the history and physical examination, the physician should follow several rules: Record all pertinent data. Avoid extr

27、aneous data. Use common terms. Avoid nonstandard abbreviations. Be objective. Use diagrams or pictures when indicated. Laboratory Examinationrecord all those data that are associated with diagnosis, including routing tests and other laboratory tests 24 h after admission. Laboratory Examinationexamin

28、ation of blood cell血液细胞学检查examination of marrow cell骨髓细胞学检查examination of hemostasis and coagulation出血和凝血的检查kidney function examination 肾功能检查liver function examination肝功能检查endocrine test内分泌试验immunological examination免疫学检查blood gas assay血气分析stool examination大便检查urine examination小便检查fluid examination液

29、体检查Bacterial culture 细菌培养Diagnosis/ImpressionThe diagnosis after analysis of the state of the caseDifferent types: primary diagnosis, final diagnosis, complete diagnosisNoun phrases are usedSOAP （Progressive Note）SOAP is a method of documentation employed by health care providers to write out notes

30、in a patients chart SOAP（Progressive Note）S = subjective This section describes the patients current condition in narrative form. The history or state of experienced symptoms are recorded in the patients own words. It will include all pertinent and negative symptoms under review of body systems. O =

31、 objective This section records vital signs, findings from physical examinations, results from laboratory, measurements. SOAP （Progressive Note）A= assessment This section is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagn

32、oses usually in order of most likely to least likely . P =plan In this section is recorded the treatment plan including estimated length of treatment, and discharge plans. SOAPThe length and focus of each component of a SOAP note varies depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status. Ownership of Medical Records Medical records may be regarded as aides-memoires created by the healthcare providers to assist them in the management of patient care. As s