篇一：接班记录-电子病历模板
姓名：王方刚 病案号C65238925
接班记录
姓名：王方刚性别：男 年岭：29岁 日期：2001年-2-25至3-4日
2001年-2-25日
接班看病人，患者神志清楚，无心慌，冷汗，头(转载自：www.xiaocaOfaNWen.com 小草 范 文 网:病例演讲技巧)晕，PE:BP100/60mmhg.呼吸202个/分，SaO2100%,定向力，理解力，判断力，计算力正常，瞳孔Φ3.5mm.22等大等圆，对光射过敏，水膜无黄染，皮肤未见蜘蛛症，未见出血点，双肺呼吸音汪清，心率72波/分，未及杂音，腹手软，全腹无压痛及反跳痛，肝痛（一），移浊（一），肠鸣音不亢进，双手扑翼样震颤（一），生理射反射存在，HOFFman,Babinski压症阴栓，自昨日血8：PM后无尿，可以出血后血变量低，灌注夏有灵，辅查：PT+A:PT21.7Sec. FIB 185.6mg/dl.APTT68.4sec.肾全：K4.9mmg/国。Na134mm01/L.C1 111mmo1/L.CR1.2mg/dl.BON 11mg/dl.血RT 凌晨2时80g/L，8AM 59g/L.PLT 170*109/L.考虑患已出血1900ml.门脉压力已下降，不宜视全血太多，否则门脉压力升高，易改再出血。患者凝血系列，PLT下降估计与出血有关，
宜补充全血治疗。
王辰
2001年-3-3日
接班看病人，精神尚可，神志清，回答切题，查体：血压：110/70mmg心肺（一），腹软，无压痛，及跳痛，肠鸣半5-6次/分，白天患者血压一直维持在110-120/60-70mmg,神清，无不适主诉，解1次棕是黄色大便，量约30ml.查OB(一)，今晚6时，患者入量6520ml.尿量300ml.未予处理，密切观察，病例情况夜间可安静入睡，血压心率稳定，未解大便。
李圆圆
2001年-3-4日
接班看病人，病人神志萎靡，余无不适，昨日尿少，共300ml.未解便。PE:BP100/50mg,HR 70bpm.神清，对答基本切题，双侧瞳孔等大圆，对光反射过敏，心肺（一），腹软，肠鸣音活跃，余查体同步。
患者既往血压偏高，BP120/80左右，神志既往清楚，尿量不少，而患者出现上述改变应高度怀疑有出血，予以复查血RY,630/AM.HB7.19/Dl; 11AM Hb
7.4g/Dl.至RAM患者解黑色大便1次100ml.OB(+),患者未诉头晕，心悸，仍萎蘼，至再次解黑便似，量约100ml.OB(+).
立即手以垂体叶系入，0.2u/min,持续心电血压O2监测，BP140/80mhg,手以三确系入。2Pm再次黑便，量约100ml.看病人面色苍白，瞌睡，能唤醒后回答切题，予以调大垂体系速至0.4a/min,维持血压110/70mgh,予以输血400ml.BPM复查血PT HB80g/L.考虑为血液浓缩。
此后患者病情趋稳，仍有解便，为黄色稀便，考虑出血已止信，予以调低
姓名：王方刚 病案号C65238925 垂体系速至0.3u/mn.
请示总值班陈医生：同意目前处理。
张京
篇二：病例演讲评分表
病例演讲评分表
篇三：英文病例范本
Note for Jane Doe on 4/8/03 - Chart 2646
Chief Complaint (1/1): This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use.
Location: She indicates the problem location is the chin, right temple and left temple locally. Severity: Severity of condition is worsening.
Menses: Onset : 13 years old. Interval: 22-27 days. Duration: 4-6 days. Flow: light. Complications: none.
Allergies: Patient admits allergies to penicillin resulting in difficulty breathing.
Medication History: Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001
medication was prescribed by Obstetrician-Gynecologist A.
Past Medical History: Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.
Past Surgical History: No previous surgeries.
Family History: Patient admits a family history of anxiety, stress disorder associated with mother. Social History: Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.
Review of Systems: Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic / Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.
Physical Exam:
Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.
Skin: Examination of scalp shows no abnormalities. Hair growth and distribution is normal.
Inspection of skin outside of affected area reveals no abnormalities. Palpation of skin shows no abnormalities.
Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis. Face shows keratotic papule.
Impression: Acne vulgaris.
Plan: Recommended treatment is antibiotic therapy.
Jane received extensive counseling about acne. She understands acne treatment is usually long-term. Return to clinic in 4 week(s).
Patient Instructions:
Patient received literature regarding acne vulgaris.
Discussed with the patient the prescription for Tetracycline and handed out information re garding the side effects and the proper method of ingestion.
Prescriptions:
Tetracycline Dosage: 250 mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes
_______________________ A. Dermatologist, MD
Sample Prescription
Charting Plus? - Electronic Medical Records
Dr. Dermatology, MD
DEA#:
_____________________________________________________________
Name: Jane DoeDate: 4/8/03
Addr: 1231 8th Street, Suite 222
West Des Moines , IA 50265
_____________________________________________________________
Tetracycline
250 mg capsule
BID
X_____________________________________ X_____________________________________ Substitution Permitted Dispense as written
Refills: 0
Disp: 60
Allow Generic: Yes
Sample Referral Letter
Charting Plus? - Electronic Medical Records
4/8/03
A. General Practitioner, MD
1231 8th Street, Suite 222
West Des Moines, IA 50265
Dear Dr. General Practitioner:
Jane Doe was seen in my office for follow -up after your initial referral. Thank you again for allowing me to participate in the care of your patients. In an attempt to provide your patients with quality patient care through improved communication, the following represents my notes from their last office visit:
Impression: Acne vulgaris.
Plan: Recommended treatment is antibiotic therapy.
Jane received extensive counseling about acne. She understands acne treatment is usually long-term. Return to clinic in 4 week(s).
Patient Instructions:
Patient received literature regarding acne vulgaris.
Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.
Prescriptions:
Tetracycline Dosage: 250 mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes If I may be of any further assistance in the care of your patient, please let me know. Sincerely,
A. Dermatologist, MD
Sample Patient Instructions for Acne Charting Plus? - Electronic Medical Records
Patient Instructions for Jane Doe on 04/11/2002
ACNE VULGARIS
What is it?
Acne vulgaris, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life. The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.
Signs and symptoms:
* Blackheads the size of a pinhead.
* Whiteheads similar to blackheads.
* Pustules - lesions filled with pus.
* Redness and inflamed skin.
* Cysts - large, firm swollen lesions in severe acne.
* Abscess - infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.
Causes:
Oil glands in the skin become plugged for reasons unknown but during adolescence, sex -hormone changes play some role. When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection. Acne is NOT caused by foods, uncleanliness or masturbation. Cleaning the skin can decrease its severity but sexual activity has no effect on it. A family history of acne can indicate if an individual will get acne and how severe it might be. Currently, acne can′t be prevented.
Acne can be brought on or made worse by:
* Hot or cold temperatures.
* Emotional stress.
* Oily skin.
* Endocrine (hormone) disorder.
* Drugs such as cortisones, male hormones, or oral contraceptives.
* Some cosmetics.
* Food sensitivities. Again, foods do not cause acne but some certain ones may make it worse. To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time. If acne worsens 2-3 days after consumption, then avoid this food. Acne usually improves in summer so some foods may be tolerated in summer that can′t be eaten in winter.
Treatment:
* Most cases of acne respond well to treatment and will likely disappear once adolescence is over. Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.
* If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3-5 minutes; an antibacterial soap may work better. A pre viously used wet washcloth will harbor bacteria. Don′t aggressively scrub tender lesions as this may spread infection; be gentle. Rinse the soap off for a good 1-2 minutes. Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.
Other tips that may help acne:
* Shampoo hair at least twice a week. Keep hair off of face even while sleeping as hair can spread oil and bacteria. If you have dandruff, use a dandruff shampoo. Avoid cream hair rinses. * Wash sweat and skin oil off as soon as possible after sweating and exercising.
* Use thinner, water-based cosmetics instead of the heavier oil-based ones.
* Avoid skin moisturizers unless recommended by your doctor.
* Do not squeeze, pick, rub or scratch your skin or the acne lesions. This may damage the skin
causing scarring and delay healing of acne. Only a doctor should remove blackheads.
* Keep from resting face on hands while reading, studying or watching TV.
* Try to avoid pressing the phone receiver on you chin while talking on the phone.
* Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe! Don′t use the sun to treat acne.
* Dermabrasion may be another option to treat acne scars. This is a type of cosmetic surgery to help remove unsightly scars.
Medications that may be prescribed to help acne include:
* Oral or topical antibiotics.
* Cortisone injections into acne lesions.
* Oral contraceptives.
* Tretinoin, which may increase sun sensitivity and excessive dryness, is not recommended during pregnancy.
*Accutane (isotretinoin) is a powerful drug to treat acne but causes birth defects. A woman taking this drug must be on two types of birth control and have negative pregnancy tests. This drug also increases sun sensitivity.Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.
TETRACYCLINE
Your doctor has prescribed Tetracycline for your condition. Tetracycline is a very safe antibiotic. It is not related to penicillin and an allergy to it is unusual. There are several potential side effects:
1. Tetracycline can cause nausea or heartburn.
2. Tetracycline can cause vaginitis.
3. Tetracycline can cause excessive sun burn.
CAUTIONS:
1. Do not take Tetracycline with milk or milk products (ice cream, cheese, yogurt, etc.). This will cancel out the Tetracycline. Separate the Tetracycline from these products by one and one -half hours before and after each capsule. Do have a small amount of non milk-containing food in your stomach first to prevent nausea.
2. Do not take Tetracycline if you are pregnant.
3. Do not take Tetracycline if you are taking birth control pills unless specifically instructed to do so.
4. If at the beach or skiing in the sun, use an effective sunblock (SPF-15 or greater) to prevent burning.
If problems or questions arise, call the office for assistance. Side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.
_______________________________A. Dermatologist, MD