对初次接触美国临床的你来说，书写患者的医疗文书（the Chart）也许会是第一个令你感到惶恐不安的任务。但是往往第一天住院医师就分给你个患者，要求你书写该患者的医疗文书。最常见的医疗文书包括H&P（大病历）、Progress Notes（日常病程）、Pre-OP Notes（术前小结）、OP Notes（手术记录）、Post-OP Checks（术后首程）等。大体来说美国文书要求的内容和中国医院的大同小异，但在语言、文书类别和内容详略方面会有所不同。通常我们需要“Rule of Thumb”，就是翻阅其他患者的文书或者这个患者的历史文书，模仿并且反复练习。作为访问医学生（Visiting Medical Student），我们书写的文书通常需要主治医师的修改和审核，你也可以根据主治医师的修改意见不断完善自己的文书。除此之外，本节将系统地讲解美国医疗文书的结构和要求，并结合一些例子，尽可能为实战前的你做好充分的理论准备。需要说明的是，随着你对文书的逐渐熟悉，你可以用很多缩写并且省略那些不太重要的信息。
1.H&P（大病历）
一个完整的大病历一般由病史（History）、临床检查（Physical Exam）和评估（Assessment and Plan）组成。注意病史（History）分成Complete History和Focused History，前者一般包含正常体检等，而后者是指患者有特定不适而来见你。
●病史
病史通常来说都是从患者、家属、其他医护人员以及电子医疗记录（Medical Chart）得来的，由以下几个部分组成：主诉、现病史、既往史、手术史、药物过敏史、家族史、社会史、疫苗接种史/体检结果和系统回顾。生命体征（Vital Signs）和各项化学检查（Labs）都不包括在此，而是在临床检查部分。在跟患者交流获取病史信息的时候，如果有什么症状是阴性，也需要记录，证明你的确问过这个问题，有助于其他阅读的人（如主治医师）全面了解患者。
主诉Chief Complaint（CC）
主诉是描述患者就诊最主要的原因或最明显的症状、体征，并且在Complete History和Focused History里面都应包括。主诉可以直接用患者的语句，比如“I have been lightheaded”，或者用短句描述患者访问的原因，比如“sore throat”。
例子：Chief complaint：knee pain.
Chief complaint：“I have a migraine.”
现病史History of Present Illness（HPI）
跟主诉一样，Complete History和Focused History里面都应包括现病史。现病史由开头句（Opening Line）和内容（Body）组成。
Opening Line是现病史的第一句话，应包括名字、年龄、性别、相关病史以及就诊原因。描述性别的时候，别用“Male/Female”，因为刁钻的主治医师会觉得“Male/Female”并没描述这是人，然而用“Male Human”又太过了。也别用“Gentleman/lady”，同样主治医师会问“你怎么知道他是‘gentleman’，他行为举止很‘nice’吗？”所以为安全起见，用“Man/Woman”最好。相关病史应包括任何与现在访问疾病有关的慢性病，以及与现有症状相关器官的疾病或手术（比如heart disease for chest pain，prior stroke for arm weakness，prior gallbladder surgery for abdominal pain）。开头句与跟主治医师汇报病例时的“One-Line Speech”极为相似。
例子：
Mr.Smith is a 75 years old man with a history of hypertension who presents with chest pain.
Mr.Jones is a 27 years woman with no significant past medication history who now presents with nausea.
Body of HPI是关于患者现有健康问题的详细记录。按照时间顺序记录患者病情发生发展的详细情况，尽量包括日期和时间，要记录与之相关的所有内容，就算患者描述的某些事情不算重要。如果是体检，要在现病史里提到患者来是为了全面体格检查（Full Physical）；如果是慢性病的随访，要记录自从上次访问之后病情的任何变化以及药物副作用等；如果是新的健康问题，现病史应包括相关病史，以及新症状的七个方面，分别是：（1）Location；（2）Quality：患者描述症状（比如Dull Pain or Sharp Pain）；（3）Severity；（4）Timing/Chronicity：什么时候开始，频率，持续时间；（5）Relieving Factor：患者用什么方式缓解症状，是否有效；（6）Augmenting/Precipitating Factor：任何可以导致症状发生或者加强病痛的因素；（7）Associated Symptoms：比如发烧，胸闷，头痛等。
例子：
Complete History
HPI：Lisa Simpson is a 7 years old girl.
小贴士
有些患者的病史非常复杂，如果这些复杂的病史与你所在的专科无关，在汇报的时候可以简略带过，与专科有关的则要仔细说。
With no relevant past medical history who presents for an annual physical exam.She is going to summer music camp in New Orleans and needs paperwork filled out for this.Her mother also wonders if she needs any vaccines before going to her camp.She has been feeling well and has no further complaints.
Focused History
HPI：Mr.Simpson is a 50 years old male with a history of coronary artery bypass surgery and anxiety who presents with heart palpitations.They began two weeks ago after taking his wife’s diet pills.The palpitations occur once per day since then and last for 3～5 minutes.They are often triggered by running after his son,Bart.He describes the palpitations as a“fluttering”in the middle of his chest,which is severe enough that it makes him stop running right away.Drinking a can of Duff beer makes the palpitations go away.He denies any chest pain or shortness of breath.He does not smoke cigarettes and denies any other drug use.He notes that he has been under increased stress at work.He fears that the palpitations may be signs of a heart attack.His father had a heart attack at age 70.
过去史/既往史Past Medical History（PMH）
过去史/既往史是患者所患过疾病的列表。Complete History的列表应包括诊断、患病日期或年龄、并发症、治疗手段以及当时主治医师的联系方式。但是像咽喉疼痛、感冒等小病则可以免去这些内容。Focused History可以只包括诊断和日期。任何跟主诉有关的既往史都应该写在病史里面。
例子：
Past Medical History
—Asthma-diagnosed age 10,hospitalized 3 times,intubated once at age 14.
—Type 1 diabetes mellitus-diagnosed at age 5 when hospitalized for DKA.
—Breast cancer-diagnosed at age 45,treated with partial mastectomy done by Dr.Wu and radiation therapy followed by tamoxifen.Sees her oncologist,Dr.Martinez,yearly.
—Shingles at age 46.
—Allergic rhinitis.
手术史Past Surgical History（PSH）
手术史需要包括手术原因、手术日期、并发症以及主刀医师的名字。智齿拔除以及扁导体切除等小手术也应记录在手术史里。跟既往史一样，如果与主诉有关的手术应包括在病史里面。
例子：
Past Surgical History
—Tonsillectomy in 1981 for recurrent pharyngitis,by Dr.Wagner.
—Appendectomy in 1987 for appendicitis,by Dr.Shah.Complicated by wound infection.
药物Medications（Meds）
药物应该包括所有处方（Prescribed）药物、非处方（Over The Counter,OTC）药物、使用补充剂（Supplements）和维生素（Vitamin），同时应该包括各种形式的外用药，比如眼药水等。药物列表应该包括药名、剂量（Dose）、服用方式和频率。通用名药全用小写（如Acetaminophen），而品牌名用大写（如Tylenol）。
服用方式有以下几种：
＊Oral（口服，或者“po”for per ora）
＊Topical（外敷）
＊Inhaled（吸入）
＊Nasal spray（鼻腔，nasal inhalation）
＊Subcutaneous（皮下，subQ or Sub-Q）
＊Intramuscular（肌内，或者IM）
＊Sublingual（舌下腺，also written as SL）
＊Rectal（直肠，also written as PR）
＊Vaginal（阴道，also written as PV）
＊Drops for ears or eyes（also written as gtt/gtts）
服用频率可以写成number of times per day（per week,per month），或者number of hours between doses（every 4 hours）.书写服用频率时，一般都用以下简写：
＊qday（once per day,also written as daily）
＊BID（twice per day）
＊TID（three times per day）
＊QID（four times per day）
＊q4h（every four hours）
＊qAC（before every meal）
＊qHS（every evening,HS＝hora somni,or hour of sleep）.
若是需要时使用，注“prn”（拉丁文pro re nata）并写上使用的原因，例如“acetaminophen 650 mg by mouth q6h prn headaches”。
例子：
Medications
—Prilosec 20 mg po qday.
—Ibuprofen 400 mg po BID prn menstrual cramps.
—Albuterol 1-2 puffs inhaled q4-6 hours prn shortness of breath.
—Centrum multivitamin 1 tablet po qday.
—Hydrocortisone 1%cream apply to affected area BID.
—Ginko biloba 120 mg 1 pill po qday.
小贴士
如有药物过敏史，需要知道儿童还是成年时过敏，什么情况下过敏以及当时过敏的表现。
过敏史Allergies
大多数医师只用Allergy list记录药物过敏反应。当然你也可以用它来记录医疗环境物品的过敏（CT/MRI contrast dye,iodine,latex）、食物过敏、季节性过敏。如果患者没有任何过敏原，则记录“No Known Drug Allergies”，或“NKDA”。如果患者有药物过敏，则需要记录药物名称、过敏症状，这样如果症状严重，可以避免使用此类药物。
例子：
Allergies
—Aspirin（anaphylaxis）
—CT contrast dye（rash）
—Simvastatin（muscle aches）
—Lisinopril（cough）
Allergies：NKDA
家族史Family History（FHx）
家族史应只包括与患者有血缘关系的亲属（Genetic Relatives）。如果是收养的，则注明“Patient is adopted”。家族史列表应按照以下顺序：Parents、Siblings、Children、Extended Family（Grandparents,Aunts/Uncles,Cousins）。疾病发生年龄也应同时记录。如果亲属已去世，则写上死因和去世年龄。
例子：
Family History
—Mother：died of lung cancer at age 68.
—Father：died of stroke at age 75,had hypertension and type 2 diabetes.
—Sister：hypothyroidism,now age 48.
—3 brothers：alive and well at age 42,46,and 50.
—Daughter：12 years old,with asthma.
—Aunt：lupus diagnosed at age 24.
—No family history of early heart disease,breast cancer or colon cancer.
社会史Social History
理论上，Complete History应包括以下所有部分：
—Occupation and highest educational level attained（if unemployed or retired,include prior occupa-tion;also note if patient is not working due to disability）.
—Birthplace,nationality and/or cultural identity.
—Living situation（type of home,who they live with,pets）.
—Relationship status.
—Sexual history（include all components as discussed in your clinical skills course）.
—Tobacco use（include amount used and duration of use;amount in pack-years is also acceptable）.
—Alcohol use（include amount used and frequency of use）.
—Recreational drug use（include names,routes of administration,amount used,and frequency of use）.
—Diet（e.g.low-fat,kosher,vegan,followsweight watchers）.
—Exercise（type and frequency）.
—Safety（abusive relationships,weapons in the home,seat belts/helmets,smoke/CO detectors,sun block）.
—Religion/spirituality.
—Recent travel.
然而，一般Focused History只需要包括Occupation,Living Situation,Smoking,Alcohol and Recreational Drug Use即可，或者还包括其他可能有关的项目比如Recent Travel。另外，任何与主诉有关的项目也应该包括在病史里。
例子：
Complete History
—Retired,has PhD,prior physicist.
—Caribbean American,born in NYC.
—Married,lives in apartment with wife and a cat.
—Sexually active,monogamous with wife only.
—Prior smoker with 30 pack-year history,but quit last year.
—Drinks 2 beers 4 times per week.
—No other drug use.
—Vegetarian,but eats fish.
—Runs 3 miles 3 times per week
—No weapons at home,wears seat belts and uses sun block.
—Catholic,does not consider himself to be practicing now.
—Travelled to Guatemala last month.
Focused History
—Works as a nurse in the ICU.
—Lives in Washington,DC with her female partner.
—Non-smoker,used cocaine in college.
—Drinks half a bottle of wine 4 nights per week.
疫苗接种史/体检结果Immunizations/Health Maintenance
体检结果包括各种胃肠镜（Endoscopy,Colonoscopy）以及子宫颈抹片检查（Pap Smear），这类需要注明操作医师的名字和检查结果。Focused History则不需要这一部分。
例子：
Immunizations/Health Maintenance
—Tdap 5/2012.
—Influenza vaccine last November.
—Pneumovax 5/2013.
—Colonoscopy 5/2011,no polyps,done by Dr.Green.Repeat due in 2021.
—Pap smear 7/2014 normal.
—Mammogram 7/2014 normal.
系统回顾Review of Systems（ROS）
这是Complete History的一部分，对于Focused History不是必需的。ROS由器官组织的列表组成，在与患者交谈的时候用“yes or no”问题形式一个个系统问过来。
例子：
Complete History
Review of Systems：
—General：no weight loss or gain,fever or night sweats.
—Skin：no rash,itching,pigmentation,changes in hair growth or loss,nail changes.
—Head/Eyes/Ears/Nose/Throat：no visual problems,wears contact lenses,no nose bleeding,no dental difficulties,occasional mouth ulcers,no throat pain or difficulty swallowing.
—Cardiovascular：no chest pain,palpitations.
—Respiratory：no shortness of breath,wheezing,cough or hemoptysis.
—Gastrointestinal：normal appetite,no abdominal pain,heartburn,constipation,or diarrhea,or changes in stools,no rectal bleeding.
—Breast：no breast lumps or nipple discharge.
—Genitourinary：no dysuria or hematuria,menarche at age 13,menses every 27 days,last monthly period 2 weeks ago.
—Musculoskeletal：no muscle or joint pains or swelling.
—Hematologic：no excessive bleeding or bruising,no lymph node enlargement.
—Endocrine：no polydipsia,polyuria,intolerance to heat or cold.
—Neurologic：no headaches,dizziness,syncope or tremor.
—Psychiatric：no anxiety,depression,or changes in mood.
●临床检查
这个跟ROS有点类似，也是按照器官系统顺序列出，并附上详细的检查结果。对于检查结果，尽量去描述而不是去解释，比如尽量用“crescendo-decrescendo systolic murmur heard best at the right upper sternal border”而不是“aortic stenosis murmur”或“murmur from prior artificial heart valve”。
临床检查从生命体征（Vital Sign）开始，包括Temperature,Blood Pressure,Pulse（heart rate）,Respiratory Rate,Weight,Height,BMI,Oxygen Saturation by Pulse Oximetry；紧接着是患者的一般情况（General Appearance），这个只需要观察，描述患者的仪态、精神状况等，并记录你所做的检查。
例子：
Vital signs：Temp 97.8,BP 120/80,P 76,RR 12,O2 98%on room air.
Wt 175lbs,Ht 5’5”,BMI 29.1.
General：pleasant,well-appearing,no acute dis-tress.
Heent：face symmetric,pupils are equal,round,and reactive to light and accommodation,extraocular movements intact,sclerae anicteric,retinal exam with sharp disc and normal vessels,normal pinnae,normal external auditory canals,clear tympanic membranes,nasal mucosa pink,nasal septum midline,no sinus tenderness,dentition good,oropharynx without lesions or exudate.
Neck：supple,no lymphadenopathy,no thyromegaly or thyroid masses,no carotid bruits,no jugular venous distension.
Cardiac：regular rate and rhythm,normal s1s2,no murmurs,rubs,or gallops.
Pulmonary：clear to auscultation bilaterally,resonant to percussion.
Breast：symmetric,no skin changes or masses bilaterally,no nipple discharge or axillary lymphadenopathy.
Abdominal：soft,normoactive bowel sounds,nontender,non-distended,no hepatosplenomegaly or masses palpated.
Back：symmetric,full range of motion,no scoliosis or kyphosis,no spinous process tenderness to palpation,no costovertebral angle tenderness.
Genitourinary：（Male）external genitalia without lesions,testicles normal size,no testicular masses,（not）circumcised,no penile discharge.（Female）normal female external genitalia,vulva without lesions,vaginal mucosa pink,cervix pink and without lesions,no cervical motion tenderness,uterus anterior,midline,and not enlarged,no adnexal fullness or masses.
Rectal：Normal rectal tone,prostate smooth and normal size without nodules,stool brown and negative for occult blood.
Extremities：no clubbing,cyanosis,edema,or tenderness.No joint deformities or effusions.Full painless range of motion of bilateral shoulders,elbows,wrists,hands,hips,knees,and ankles.
Skin：no rashes,no suspicious nevi.
Neurologic：cranial nerves II-XII intact,normal muscular bulk and tone,5/5 strength in all muscle groups of bilateral upper and lower extremities,intact sensation to light touch throughout,patellar/biceps/Achilles reflexes 2＋and symmetric bilaterally,normal gait,fluent speech.
Results
这部分指相关实验室检查结果（e.g.blood tests,urinetests）、影像结果（e.g.x-rays,ultrasounds,CTscans,MRIs,bone density tests），诊室检查结果［e.g.electrocardiograms（EKGs）,strep throat swabs,urine pregnancy tests,fingerstick blood sugars］和侵入性检查结果（e.g.endoscopies,stress tests,echocardiograms,pulmonary function tests）.
●评估与计划Assessment and Plan
跟现病史一样，“评估/与计划”也有一个开头句来介绍患者名字、年龄等。不同的是，这里还需要包括此次来访过程中最重要的线索。剩下部分就根据患者的问题一个个列出来，需要陈述、评估病情，给出诊断并写下治疗方案。
陈述病情：如果是之前已经诊断的疾病，可以写“Diagnosis”，比如“Osteoporosis”。否则，写“Symptom”或者“Sign”，比如“Dyspnea”或“Hepatomegaly”。
评估病情：这是对问诊、临床检查和实验室数据的总结，需要以陈述方式写。如果是新的疾病，要以“Differential Diagnosis”开头。然后解释各个诊断的可能性高低，在解释的时候，需要考虑Demographics（人口统计学），Risk Factors（危险因素），Epidemiology（流行病学），Symptoms（病症）和Signs（体征）等因素。
给出诊断治疗方案：诊断计划和治疗方案都应以分条列出，告知读者你已经做了什么以及你将要做什么。计划里应该包括患者的咨询以及教育，手术方案，实验室检查，用药方案等同时也应该记录患者下一次预约的门诊日期。
如果患者此访是因为年检，则应列“Health Maintenance”，不需要“Assessment”。列表中应包括癌症筛查、疫苗、预防保健（内镜，牙科眼科护理）以及与患者讨论的生活方式调整。
例子：
Assessment and Plan
40 years old woman with a history of hypertension presents with dysuria for 1 day and was found to have an abnormal UAin clinic：
1）Dysuria：Differentialdiagnosisincludesurinary tract infection,sexually transmitted infection（gonorrhea,chlamydia）,and vaginal atrophy.Given that the patient is premenopausal with regular periods,vaginal atrophy is very unlikely.Patient is currently sexually active but with the same male partner for the last 6 years and it is a monogamous relationship,making STI less likely but still possible,as they do not use condoms.Bacterial UTI is the most likely diagnosis given her frequent urination and urinary urgency along with dysuria in this 40 years old woman.
Ordered urinalysis to look for evidence of bacterial infection,which is positive for leukocyte esterase here in clinic.
Will treat for likely urinary tract infection with ciprofloxacin 250 mg po BID for 3 days.Side effects discussed with patient including diarrhea,development of yeast infection,and rare possibility of tendon rupture.
Order urine test for gonorrhea and chlamydia to rule out STI as cause.
Instructed patient to call if her symptoms worsen or fail to improve within 48 hours,or if she develops fever or back pain.
2）Hypertension:well controlled,as blood pressure at goal of<140/90.Tolerating medication with-out side effects.
Continue lisinopril 10mg po qday and low sodium diet.
Return to clinic in 6 months for follow-up of blood pressure.
表3－1是大病历内容的清单，供参考。
表3－1 病史询问内容清单
续表
续表
此外，注意在PE中有不少缩写可供使用，列举如下：
General:B/L＝bilateral;c/＝with;s/＝without;NT＝non-tender.
VS＝vital signs;Pox＝pulse-ox;RA＝room air（or O2@...）.
WD/WN＝welldeveloped,wellnourished;NAD＝No acute distress;AAOx3＝awake,alert,oriented to person,place and time.
NC/AT＝normocephalic/atraumatic;EOMI＝extraocular muscles intact;PERRLA＝pupils equal,round,reactive to light&accommodation;TM＝tympanic membrane;LR＝light reflex;MMM＝moist mucous membranes.
ROM＝range of motion;LAD＝lymphadenopathy.
CT A/P＝clear to auscultation&percussion;W/R/R＝wheezes/rales/ronchi.
RRR＝regular rate&rhythm;M/R/G＝murmur/rubs/gallops;PMI＝point of maximum impulse.
HSM＝hepatosplenomegaly;BS＝bowel sounds;CVA＝costo-vertebral angle.
C/C/E＝cyanosis,clubbing,or edema;DP/PT＝dorsalis pedis/posterior tibilalis.
MS＝mental status;CN＝cranial nerve;RAM＝rapid alternating motion;MMSE＝mini-mental status exam.
神经系统的体格检查有时可简写成“AAOx3,CN II-XII grossly intact;non-focal exam”。
2.Progress Notes（日常病程）
如果你在病房，日常病程是你必然需要接触的文书。日常病程的内容较大病历简单，大多是以SOAP为架构的，即Subjective（主诉），Objective（客观依据：查体及辅助检查），Assessment（目前评估与诊断），Plan（计划）。每一部分的内容会在“汇报病史”那一节详细介绍。其实这部分和国内的思路差别不大，只是需要注意，如果患者在用抗生素，需要把具体的抗生素名称和剂量以及开始服用和停药时间写清楚。
3.Pre-OP Notes（术前小结）
如果你在外科，术前小结是你一定会接触到的。相信在国内每个人都或多或少接触过术前小结。美国的术前小结和国内的差别不大，即对患者术前准备情况的总结，在此将常见的术前小结形式举例如下：
Date：
Time：
Pre-op Diagnosis：
Procedure：
Pre-Op Orders written：e.g.ABx,NPO,Bowel prep,etc
Labs：CBC,electrolytes,PT/PT,U/A
CXR：NAD（no active disease）,or note any abnormalities
EKG：NSR（normal sinus rhythm）,rate,normal intervals,axis,no ST-wave changes,or note any abnormalities
Blood：Typed and crossed or screened（T&C/S）,number of units
Consent：Signed and on chart
Anesthesia：To see patient,or patient seen,note on chart
Consultants-if applicable
Signature
Print name,VMS
Pager number
免责声明：以上内容源自网络，版权归原作者所有，如有侵犯您的原创版权请告知，我们将尽快删除相关内容。
