如何書寫患者記錄如何書寫患者記錄患者記錄是記錄病人的基本信息，包含病人的個(gè)人信息和就診信息。Patient

Record0102Personal

informationCommon

expressionsPartOnePersonalinformationpersonal

information個(gè)人信息就診日期和時(shí)間姓Date&Time

:Firstname

:Surname

:名出生日期職業(yè)DOB

:date

ofbirth:性別(F/M)female女士/male男士Gender

:Occupation:maritalstatus:

婚姻情況（Married/Single

已婚/未婚）直系親屬聯(lián)系方式Next

ofkin

:Contact

No.

:medical

information患者服藥史有無吸煙史有無飲酒史有無過敏史不適用的Smokingintake:Alcoholintake

:Allergies

:N/A:not

applicable

:住院原因Reasonfor

admission:有無家族遺傳病史Familyhistory:Part

TwoCommonExpressions你的職業(yè)是什么？我是一名教師/農(nóng)民。。。What'syour

occupation?I’mateacher/farmer...Caniaskaboutyour

martialstatus?我能問一下你的婚姻狀況嗎？I’msingle/married/unmarried.我單身/已婚/未婚。誰是您的護(hù)理者？我的女兒/兒子/父母Who

is

your

caregiver?Mydaughter/son/parentsHesmokes6cigarettesper

dayanddrinkstwicea

week.他每天抽6支煙，每天喝兩杯。Thereisahistoryof

heartdisease

onhismother’sside.他母親有心臟病史。Heis

notallergic

toanything.他對(duì)任何東西都不過敏。PatientRecordDate&Time

9:50

3/11/2014Surname

StewardsDOB

24/05/1957First

name

PeterGender

MMarital

status

marriedOccupation

Bus

driverNext

of

kin

daughterContact

No.

324-555-84Alcohol

intake

twice

a

weekAllergies

N/ASmoking

intake

six

per

dayReason

for

admission

DiabetesFamily

history

Heart

disease(mother

’s

side)AssignmentPatientRecordDate&TimeSurnameFirst

nameDOBGenderMarital

statusOccupationNext

of

kinContact

No.Alc