病历文书中常用用语的英文翻译（太实用了！）

病历文书中常用用语的英文翻译

1、抗生素医嘱[Antibiotic order]

Prophylaxis [预防性用药]

Duration of order[用药时间] 24hr

Procedure[操作，手术]

Empiric therapy [经验性治疗]

Suspected site and organism[怀疑感染的部位和致病菌]

Cultures ordered[是否做培养]

Documented infection[明确感染]

Site and organism[部位和致病菌]

Other[其它]

Explanation required [解释理由]

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]

Activity [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]l

P[脉博]

Bp[血压]

R[呼吸]

T[温度]

Height[身高]

Weight[体重]

General[概况]l

HEENT[五官]

Neck[颈部]

Back/Chest[背部/胸部]

Breast[乳房]

Heart[心脏]l

Heart rate[心率]

Heart rhythm[心律]

Heart Border[心界]

Murmur[杂音]

Abdomen[腹部]l

Liver[肝]

Spleen[脾]

Rectal[直肠]

Genitalia[生殖系统]

Extremities[四肢]l

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]:

*Hb

*

*cardio-pulmonary bypass with anticipated Hb [心肺分流术伴预计血色素 ]

*chemotherapy or surgery with Hb

▲全血[whole blood]:

massive on-going blood loss[大量出血]

▲血小板[platelets]:

*massive blood transfusion

*platelet count

*Cardio-pulmonary bypass uith pl

*Platelet count

▲新鲜冰冻血浆[fresh frozen plasma]:

*documented abnormal PT or PTT with bleeding orSurgery[PT、PTT异常的出血或手术病人]

*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手术者]

*blood transfusion

*warfarin or antifibrinolytic therapy withbleeding[华法令或溶栓治疗后出血]

*DIC[血管内弥漫性凝血]

*Antithrombin III dficiency[凝血酶III 缺乏]

(2)输血要求[request for blood components]

*patient blood group[血型]

*Has the patient had transfusion or pregnancy in the past 3 months? [近3个月，病人是否输过血或怀孕过?]

*Type and crossmatch [血型和血交叉]

*Units or ml[单位或毫升]

5、出院小结[discharge summary]

Patient Name[病人姓名]l

Medical Record No.[病历号]l

Attending Physician[主治医生]l

Date of Admission[入院日期]l

Date of Discharge[出院日期]l

Principal Diagnosis[主要诊断]l

Secondary Diagnosis[次要诊断]l

Complications[并发症]l

Operation[手术名称]l

Reason for Admission[入院理由]l

Physical Findings[阳性体征]l

Lab/X-ray Findings[化验及放射报告]l

Hospital Course[住院诊治经过]l

Condition[出院状况]l

Disposition[出院去向]l

Medications[出院用药]l

Prognosis[预后]l

Special Instruction to the Patient(diet,physical activity)[出院指导(饮食，活动量)]l

Follow-up Care[随随访]l

6、住院/出院病历首页[Admission/discharge record]

Patient name[病人姓名]

race[种族]

address[地址]

religion[宗教]

medical service[科别]

admit (discharge) date[入院(出院)日期]

Length of stay [住院天数]

guarantor name [担保人姓名]

next of kin or person to notify[需通知的亲属姓名]

relation to the patient[与病人关系]

previous admit date[上次住院日期]

admitting physician [入院医生]

attending physician [主治医生]

admitting diagnosis[入院诊断]

final (principal) diagnosis[较终(主要)诊断]

secondary diagnosis[次要诊断]

adverse reactions (complications)[副作用(合并症)]

incision type[切口类型]

healing course[愈合等级]

operative (non-operative) procedures[手术(非手术)操作]

nosocomial infection[院内感染]

consultants [会诊]

Critical-No. of times[抢救次数]

recovered-No. of times[成功次数]

Diagnosis qualitative analysis[诊断质量]

OP.adm.and discharge Dx concur [门诊入院与出院诊断符合率]

Clinical and pathological Dx concur[临床与病理诊断符合率]

Pre- and post-operative Dx concur [术前术后诊断符合率]

Dx determined with in 24 hours (3 days) afteradmission[入院后24小时(3 天)内确诊]

Discharge status[出院状况]

recovered[治愈]

improved[好转]

not improved[未愈]

died [死亡]

Dispositon[去向]

home[家]

against medical ad[自动出院]

autosy[尸检]

transferred to[转院到]

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