1、抗生素医嘱[Antibiotic order]
        •Prophylaxis [预防性用药]     Duration of oder[用药时间]   24hr
          Procedure[操作，手术]
        •Empiric theraphy [经验性治疗]
          Suspected site and organism[怀疑感染的部位和致病菌]       72hr
          Cultures ordered[是否做培养]
        •Documented infection[明确感染]
          Site and organism[部位和致病菌]                         5days
        •Other[其他]
          Explanation required [解释理由]                          24hr
        •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]
        •Acitivity [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]               医学全在线www.med126.com
          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]    
        P[脉博]   
        Bp[血压]    
        R[呼吸]
          T[温度]           
          Height[身高]   
          Weight[体重]
         General[概况]      
          HEENT[五官]  
          Neck[颈部]
        Back/Chest[背部/胸部]         
        Breast[乳房]
         Heart[心脏] 
          Heart rate[心率]  
          Heart rhythm[心律]  
          Heart Border[心界]
        Murmur[杂音]  
         Abdomen[腹部]  
              Liver[肝]    
              Spleen[脾]
              Rectal[直肠]   
         Genitalia[生殖系统]   
         Extremities[四肢]
         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<8.5 [血色素<8.5]
        *>20% blood volume lost [>20%血容量丢失]
        *cardio-pulmonary bypass with anticipated Hb <8[心肺分流术伴预计血色素
         <8]
        *chemotherapy or surgery with Hb <10[血色素<10的化疗或手术者]
        ▲全血[whole blood]:
        massive on-going blood loss[大量出血]
        ▲血小板[platelets]:
        *massive blood transfusion >10 units[输血10单位以上者]
        *platelet count <50×103/μl with active bleeding or surgery[血小板<5万伴活
          动性出血或手术者]
        *Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流
          术伴血小板<10万，活动性出血者]
        *Platelet count <20×103/μl[血板<2万]
        ▲新鲜冰冻血浆[fresh frozen plasma]:
        *documented abnormal PT or PTT with bleeding or Surgery[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 >15units[输血>15个单位]
        *warfarin or antifibrinolytic therapy with bleeding[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]           
         Medical Record No.[病历号]
         Attending Physician[主治医生]     
         Date of Admission[入院日期]
         Date of Discharge[出院日期]       
         Pirncipal Diagnosis[主要诊断]
         Secondary Diagnosis[次要诊断]    
         Complications[并发症]
         Operation[手术名称]             
         Reason for Admission[入院理由]
         Physical Findings[阳性体征]       
         Lab/X-ray Findings[化验及放射报告]
         Hospital Course[住院诊治经过]    
         Condition[出院状况]
         Disposition[出院去向]            
         Medications[出院用药]
         Prognosis[预后]
         Special Instruction to the Patient(diet, physical activity)[出院指导（饮食，活动量）]
         Follow-up Care[随随访]
        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 patient[与病人关系]
        •previous admit date[上次住院日期]
        •admitting physician [入院医生]
        •attending phgsician[主治医生]
        •admitting diagnosis[入院诊断]
        •final (principal) diagnosis[最终（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]
        •consutants[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) after admission[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]
        来源：医学全在线