Englishnursingmedicalrecordpresentationcontents目錄IntroductionOverviewofEnglishnursingmedicalrecordsCommonexpressionsinEnglishnumberingmedicalrecordsCommonvocabularyandphrasesinEnglishnumberingmedicalrecordscontents目錄ReadingandAnalysisofEnglishNursingMedicalRecordsPracticeofWritingEnglishNurseMedicalRecords01IntroductionTodiscusstheimportanceofaccuracyandcomprehensivedocumentationinnursingcareToexplorewaystoimprovethepresentationandaccessibilityofnumberingmedicalrecordsToprovideanoverviewofthenumberingmedicalrecordsystemPurposeofspeechThenursingmedicalrecordisacriticalcomponentofhealthcaredelivery,documentingtheassessment,diagnosis,treatment,anddischargeofpatientsHowever,challengessuchasillegiblehandling,incompleteinformation,andinaccessibilitytorecordscanleadtoadverseoutcomesandmedicalissuesAccurateandcomprehensivedocumentationisessentialforensuringpatientsafety,continuityofcare,andlegalcomplianceBackgroundofspeech02OverviewofEnglishnursingmedicalrecordsAccuracyandconsistencyEnglishnursingmedicalrecordsprovideaconsistentandaccuraterecordofpatientcare,enablinghealthcareprofessionalstoprovidebetter,morecoordinatedcareCommunicationtoolEnglishnursingmedicalrecordsserveasacommunicationtoolamonghealthcareproviders,facilitatinginformationsharingandenhancingcollaborationLegalrequirementInmanycounties,maintainingEnglishnursingmedicalrecordsisalegalrequirement,ensuringaccountingabilityandprotectingagainstmedicalmalpracticesuitsTheimportanceofEnglishnursingmedicalrecords

TheformatandcontentofEnglishnursingmedicalrecordsDateandtimeDocumentthedateandtimeofeachpatientaccountant,includingassessments,interventions,andobservationsPatientinformationIncludebasicpatientinformationsuchasname,dateofbirth,andcontactdetailsMedicalhistoryRecordthepatient'spastmedicalhistory,includinganyrelatedsurgeries,allergys,andchronicconditionsCurrenthealthstatus:Describethepatient'scurrenthealthstatus,includinganysymptoms,vitalsigns,andpermanentpositiveornegativefindingsfromphysicalassessmentsTheformatandcontentofEnglishnursingmedicalrecordsDocumentthecareplan,includingthenursingdiagnosis,goals,interventions,andexpectedoutcomesCareplanRecordanychangesinthepatient'sconditionorprogresstowardsachievingthecareplanProgressnotesEnsurethatallentriesaresignedanddatedbytheresponsiblenurseorhealthcareproviderSignaturesTheformatandcontentofEnglishnursingmedicalrecords03UseheadingsandsubheadingsUseheadingsandsubheadingstoorganizeinformationandmakeiteasiertonavigatethroughtherecord01UseclearandconsensuslanguageAvoidusingjargonorabrasionsthatmaybeunfriendlytootherhealthcareproviders02OrganizeentrieslogicallyArrangeentriesinalogicalorder,groupingsimilarinformationtogetherforeachreferenceWritingskillsforEnglishnursingmedicalrecordsHighlightimportantinformationUseboldface,italics,orunderlyingtohighlightimportantinformationsuchasvitalsignsthatareexternalnormalrangesorsignificantchangesinthepatient'sconditionDocumentchangesDocumentanychangesinthepatient'sconditionorprogresstowardsachievingthecareplanWritingskillsforEnglishnursingmedicalrecords03CommonexpressionsinEnglishnumberingmedicalrecordsThepatienthasatemperatureof38.5°C,withchildrenandeatingOverCoughShortnessofbreathJointpaintThepatientexperiencesdrycough,whichismoresevereatnightThepatientfeelsshortofbreathwhenwalkingorengaginginphysicalactivitiesThepatientexperiencespaintinthejoints,specificallyinthemorningSymptomdescription010204DiagnosticresultsThepatient'sbloodpressureis140/90,indicatinghypertensionThepatient'sheartrateis100beatsperminute,whichisslightlyelevatedThepatient'sbloodsugarlevelis120mg/dL,indicatingprediabetesThepatient'selectrocardiogramshowssignsofatmosphericfibrosis03Treatmentplanning01Thepatientwillbesubscribedmedicinetolowertheirbloodpressureandcontroltheirheartrate02Thepatientwillbeadvisedtomakelifestylechanges,includingdieandexercise03Thepatientmayneedtogounderfurtherteststoassesstheirbloodsugarandelectrocardiogramabnormalities04Thepatientwillbereferredtoacardiologistforfurtherevaluationandmanagementoftheiratmosphericfiltration輸入標題02010403NursingplanThepatientwillbemonitoredcloselyforanychangesintheirconditionsThepatientwillbereferredtoadietaryforfurtherguidanceontheirdietThepatientwillbeadvisedtoavoidtriggersthatmayexcerbatetheirsymptoms,suchascertainfoodsoractivitiesThepatientwillbeprovidedwitheducationonself-managementoftheircondition,includingdie,exercise,andmedicaleducationThepatientshouldavoidstrenuousactivitiesuntiltheirconditionimprovesThepatientshouldcontacttheirhealthcareproviderimmediatelyiftheyexperienceanyworrisomesymptomsorsideeffectsfromtheirmedicineThepatientshouldmaintainahealthylifestyle,includingabalanceddieandregularexercisetocontroltheirconditionsThepatientshouldavoidsmokingandlimitalcoholconsumptiontoreducetheriskoffurthercomplicationsMedicaladviceandprecautions04CommonvocabularyandphrasesinEnglishnumberingmedicalrecordsFever:highheatCough:CoughSymptomrelatedvocabularySorethroat:Diarra:DiarrheaSymptomrelatedvocabularyFatigue:ShortnessofbreathSymptomrelatedvocabulary0102SymptomrelatedvocabularyHeadacheJointpainDiagnosticrelatedvocabularyPhysicalexaminationImagingstudies:ImagingexaminationsDiagnosticprocedures:diagnosticproceduresLabtests:LaboratorytestsNursingcareSurgicalprocedure:SurgicaltreatmentMedication:DrugtherapyRehabilitation:RehabilitationtherapyPalliativecare:palliativecareTerminologyrelatedtotreatmentandcare010302040501030402VocabularyrelatedtomedicaladviceandpreparationsPrecaution:PreventivemeasuresSelfcareadvice:self-careadviceRestandrelaxationadviceMedicationinstructions:Medicationinstructions05ReadingandAnalysisofEnglishNursingMedicalRecordsMethodsandtechniquesforreadingEnglishnursingmedicalrecordsFamilywithmedicalterms:ItisessentialtobeafamilywithmedicaltermsusedinEnglishnumberingmedicalrecordstounderstandthepatient'scondition,treatment,andprogressSkillsindecision-makingabrasions:EnglishnursingmedicalrecordsoftenuseabrasionstosavespaceandtimeItisnecessarytohavetheskillstodecisiontheseadmissionscorrectlyUnderstandingofthestructureandformat:UnderstandingthestructureandformatofEnglishnursingmedicalrecordshelpstoquicklylocateimportantinformationandunderstandtheoverallsituationofthepatientUseofdictionariesandonlineresources:Whenaccountingforunfamiliarwordsorphrases,usingdictionariesoronlineresourcescanhelpquicklyunderstandtheirmeaningsThestepsandkeypointsofanalyzingEnglishnursingmedicalrecordsSummarizethepatient'scondition:Summarizethepatient'scondition,includingchildcomplaints,pasthistory,personalhistory,familyhistory,andphysicalexaminationfindingsIdentifynursingdiagnosis:Basedonthepatient'scondition,identifynursingdiagnosisandprioritizethemaccordingtotheirimportanceandurgencyDeterminenumberinginterferences:Accordingtothenumberingdiagnosis,determinethecorrespondingnumberinginterferences,includinggoals,measures,evaluationmethods,andexpectedoutcomesDocumentnumberingprogress:Regularlydocumentthepatient'sprogressinthenumberingprocess,includingchangesinconditions,responsestotreatment,andevaluationresultsSuggestionsforimprovingthereadingabilityofEnglishnursingmedicalrecordsIncreasevocabulary:ExpandyourvocabularybylearningmoremedicaltermsandabbreviationsusedinEnglishnumberingmedicalrecordsPracticereading:RegularlyreadEnglishnursingmedicalrecordstofamiliarizeyourselfwiththelanguageandformatusedAttentiontrainingcourses:AttentiontrainingcoursesonhowtoreadandanalyzeEnglishnursingmedicalrecordstoimproveyourskillsandknowledgeSeekhelpfromprofessionals:IfyouenrollstudentsinreadingoranalyzingEnglishnumericalmedicalrecords,seekhelpfromprofessionaltranslatorsornumberswhoarefamilieswiththisarea06PracticeofWritingEnglishNurseMedicalRecords0102Step1Gatherinformation:Collectallrelevantinformationaboutthepatient'scondition,treatment,andprogressStep2Arrangeinformation:OrganizetheinformationinalogicalandcoherentmanStep3Writeclearly:Usesimple,clearlanguagetoensurethattherecordiseasytounderstandStep4Includeall