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天风翻译西安医学翻译公司：病历中英文翻译

发布时间：2010/10/21 阅读次数：11438 字体大小: 【小】【中】【大】

天风翻译西安医学翻译公司：病历中英文翻译

住院文书格式[Admission document]

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] 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[其它]

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]

•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]

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]

 Principal 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 physician [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]

•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) 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]

general hospital综合医院

children hospital儿童医院

tumour hospital肿瘤医院

chest hospital 胸科医院

field hospital野战医院

isolation hospital隔离医院

military hospital陆军医院

municipal hospital市立医院

maternity hospital产科医院

mental hospital精神医院

infectious hospital传染医院

leprosy hospital麻风医院

affiliated hospital附属医院

training hospital教学医院

out-patient department门诊部

In-patient department住院部

Nursing department护理部

Admission office住院处

Discharge office 出院处

Registration office挂号处

Reception room, waiting room侯诊室

Consultation room诊察室

Isolation room隔离室

Labour room待产室

Delivery room分娩室

Emergency room急诊室

Ward病房室

Pharmacy dispensary药房

Nutrition department营养部

Diet- preparation department配膳室

Therapeutic department治疗室

Operating room手术室

Blood-bank血站

Supply-room供应室

Disinfection-room消毒室

Dressing room 换药室

Mortuary太平间

Record room病案室

Department of internal medicine内科

Department of surgery外科

Department of pediatrics儿科

Department of obstetrics and gynecology妇科

Department of neurology神经科

Department of ophtalmology眼科

E.N.T.department耳鼻喉科

Department of stomatology口腔科

Department of urology泌尿科

Department of orthopedic骨科

Department of traumatology创伤科

Department of endocrinology内分泌科

Department of anesthesiology麻醉科

Department of dermatology皮肤科

Department of infectious diseases传染病科

Department of pathology病理科

Department of psychiatry精神科

Department of orthopacdic surgery矫形外科

Department of cardiac surgery心脏外科

Department of cerebral surgery脑外科

Department of thoracic surgery胸外科

Department of plastic surgery矫形外科

Department of physiotherapy理疗科

electrotherapy room电疗科

heliotherapy room光疗科

wax-therapy room蜡疗科

hydrotherapy room水疗科

central laboratory中心实验室

clinical labororatory临床实验室

bacteriological labororatory细菌实验室

biochemical labororatory生化实验室

serological labororatory血清实验室

X-ray room X光室

doctor’s office医生办公室

nurse”s office护士办公室

director of the hospital院长

head of the nursing department护理部主任

attending doctor主治医师

resident doctor住院医师

intern doctor实习医师

chief physician主任医师

associate chief physician副主任医师

physician内科医师

urological surgeon泌尿外科医师

neurosurgeon 神经外科医师

plastic surgeon矫形外科医师

anestheist麻醉科耳医师

E.N.T.doctor耳鼻喉科医师

Ophthalmolgist眼科医师

Dentist牙科医师

Dermatologist皮肤科医师

Doctor for tuberculosis结核科医师

Physiotherapist理疗科

Doctor for infectious diseases传染病科

Dietician营养科医师

Pediatrist儿科医师

Obstetrician产科医师

Midwife 助产师

Gynecologist妇科医师

Orthopedist骨科医师

Radiologist放射科医师

Epidemiologist 流行病医师

Hygiemist卫生医师

Pharmacist药剂医师

Assistant pharmacist药剂医士

X-ray techmicianX光技师

Laboratory technician化验员

Head nurse护士长

Student nurse实习护士

Assistant nurse卫生员

Cleaner清洁员

Controller总务科长

Registrar 挂号员

Sanitation worker消毒员

First visit初诊

To attend the clinic复诊

Out-call出诊

Case history病历

Sheet-for-case history病历袋

Turnover of beds病床周转率

Average of hospital stay平均住院日数

Ward round查房

Consultation 会诊

Medical certification诊断书

Certification for leave of absence病假证明

Application for laboratory examination化验申请单

Application for X-ray examinationX光申请单

Requisition for drugs领药单

病历 case histroy

一般事项 date of admission /marital status /present address /correspondence / occupation

主诉 chief complaints

现病史 present illness / history of present illness

既往史 past medical history

家族史 family history

个人病史 personal history / social history

曾用药物 medications

过敏史 allergies

系统回顾 system review / review of system

体检 physical examination

一般资料 physical data 生理指标physical signs

一般状况或全身状况 general appearance

头眼与耳鼻喉 head ,eyes,ear,nose,throat ,略作heent.

胸部与心肺 CHEST,heart,and lungs

腹部 abodoms

四肢extremities

神经系统nervous system,Neurological,略作CNC或Neuro,

骨骼肌系统 Musculoskeletal

泌尿生殖系统 Genitourinary

化验室资料laboratory data/ studies /diagnosis

血液检查 blood test

化学7项指标 chem.-7

心脑电图 electrocardiogram / electroencephalogram , 略作 EKG/EEG

X线检查与x光片 X-ray examination, x-ray slides,

计算机X线断层扫描与核磁共振扫描资料 computerized x-ray tomography and nuclear magnetic resonance spectroscopy dta. CT AND NMR

其他检查资料 other lab data

印象与诊断 impression and diagnosis

住院治疗情况 hospital course

出院医嘱 discharge instructions / recommendations

出院后用药 discharge medications

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