病歷文書中常用用語的英文翻譯，「未名翻譯公司」是北京地區(qū)一家專業(yè)的翻譯公司，在病歷文書翻譯方面，專門負責各領域的翻譯積累了豐富的翻譯經驗。一對一服務,專業(yè)優(yōu)質翻譯,高效保質,守時保密。

1、抗生素醫(yī)囑[Antibiotic order]

Prophylaxis [預防性用藥]

Duration of order[用藥時間] 24hr

Procedure[操作，手術]

Empiric therapy [經驗性治療]

Suspected site and organism[懷疑感染的部位和致病菌]

Cultures ordered[是否做培養(yǎng)]

Documented infection[明確感染]

Site and organism[部位和致病菌]

Other[其它]

Explanation required [解釋理由]

Antibiotic allergies[何種抗生素過敏]

No known allergy [無已知的過敏]

Drug+ dose+ Route+ frequency[藥名+劑量+途徑+次數(shù)]

2、醫(yī)囑首頁[Admission / transfer]

Admit / transfer to [收入或轉入]

Resident [住院醫(yī)師] Attending[主治醫(yī)師]

Condition [病情]

Diagnosis[診斷]

Diet [飲食]

Activity [活動]

Vital signs[測生命體征]

I / O [記進出量]

Allergies[過敏]

3、住院病歷[case history]

Identification [病人一般情況]

Name[性名]

Sex[性別]

Age [年齡]

Marriage[婚姻]

Person to notify and phone No.[聯(lián)系人及電話]

Race[民族]

I.D. No.[身份證]

Admission date[入院日期]

Source of history[病史提供者]

Reliability of history[可靠程度]

Medical record No[病歷號]

Business phone No.[工作單位電話]

Home address and phone No.[家庭住地及電話]

Chief complaint[主訴]

History of present illness[現(xiàn)病史]

Past History[過去史]

Surgical[外科]

Medical[內科]

Medications[用藥]

Allergies[過敏史]

Social History[社會史]

Habits[個人習慣]

Smoking[吸煙]

Family History[家族史]

Ob/Gyn History[ 婚姻/生育史]

Alcohol use[喝酒]

Review of Aystems[系統(tǒng)回顧]

General[概況]

Eyes, Ears, Nose and throat[五官]

Pulmonary[呼吸]

Cardiovascular[心血管]

GI[消化]

GU[生殖、泌尿系統(tǒng)]

Musculoskeletal[肌肉骨骼]

Neurology[神經系統(tǒng)]

Endocrinology[內分泌系統(tǒng)]

Lymphatic/Hematologic[淋巴系統(tǒng)/血液系統(tǒng)]

Physical Exam[體檢]

Vital Signs[生命體征]l

P[脈博]

Bp[血壓]

R[呼吸]

T[溫度]

Height[身高]

Weight[體重]

General[概況]l

HEENT[五官]

Neck[頸部]

Back/Chest[背部/胸部]

Breast[乳房]

Heart[心臟]l

Heart rate[心率]

Heart rhythm[心律]

Heart Border[心界]

Murmur[雜音]

Abdomen[腹部]l

Liver[肝]

Spleen[脾]

Rectal[直腸]

Genitalia[生殖系統(tǒng)]

Extremities[四肢]l

Neurology[神經系統(tǒng)]

cranial nerves[顱神經]

sensation[感覺]

Motor[運動]

Special P.E. on diseased organ system[?？魄闆r]

Radiographic Findings[放射]

Laboratory Findings[化驗]

Assessment[初步診斷與診斷依據(jù)]

Summary[病史小結]

Treatment Plan[治療計劃]

4、輸血申請單[Blood bank requisition form]

(1)reason for infusion[輸血原因]

▲紅細胞[packed red cells, wshed RBCs]:

*Hb

*

*cardio-pulmonary bypass with anticipated Hb [心肺分流術伴預計血色素 ]

*chemotherapy or surgery with Hb

▲全血[whole blood]:

massive on-going blood loss[大量出血]

▲血小板[platelets]:

*massive blood transfusion

*platelet count

*Cardio-pulmonary bypass uith pl

*Platelet count

▲新鮮冰凍血漿[fresh frozen plasma]:

*documented abnormal PT or PTT with bleeding orSurgery[PT、PTT異常的出血或手術病人]

*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏的出血/手術者]

*blood transfusion

*warfarin or antifibrinolytic therapy withbleeding[華法令或溶栓治療后出血]

*DIC[血管內彌漫性凝血]

*Antithrombin III dficiency[凝血酶III 缺乏]

(2)輸血要求[request for blood components]

*patient blood group[血型]

*Has the patient had transfusion or pregnancy in the past 3 months? [近3個月，病人是否輸過血或懷孕過?]

*Type and crossmatch [血型和血交叉]

*Units or ml[單位或毫升]

5、出院小結[discharge summary]

Patient Name[病人姓名]l

Medical Record No.[病歷號]l

Attending Physician[主治醫(yī)生]l

Date of Admission[入院日期]l

Date of Discharge[出院日期]l

Principal Diagnosis[主要診斷]l

Secondary Diagnosis[次要診斷]l

Complications[并發(fā)癥]l

Operation[手術名稱]l

Reason for Admission[入院理由]l

Physical Findings[陽性體征]l

Lab/X-ray Findings[化驗及放射報告]l

Hospital Course[住院診治經過]l

Condition[出院狀況]l

Disposition[出院去向]l

Medications[出院用藥]l

Prognosis[預后]l

Special Instruction to the Patient(diet,physical activity)[出院指導(飲食，活動量)]l

Follow-up Care[隨隨訪]l

6、住院/出院病歷首頁[Admission/discharge record]

Patient name[病人姓名]

race[種族]

address[地址]

religion[宗教]

medical service[科別]

admit (discharge) date[入院(出院)日期]

Length of stay [住院天數(shù)]

guarantor name [擔保人姓名]

next of kin or person to notify[需通知的親屬姓名]

relation to the patient[與病人關系]

previous admit date[上次住院日期]

admitting physician [入院醫(yī)生]

attending physician [主治醫(yī)生]

admitting diagnosis[入院診斷]

final (principal) diagnosis[較終(主要)診斷]

secondary diagnosis[次要診斷]

adverse reactions (complications)[副作用(合并癥)]

incision type[切口類型]

healing course[愈合等級]

operative (non-operative) procedures[手術(非手術)操作]

nosocomial infection[院內感染]

consultants [會診]

Critical-No. of times[搶救次數(shù)]

recovered-No. of times[成功次數(shù)]

Diagnosis qualitative analysis[診斷質量]

OP.adm.and discharge Dx concur [門診入院與出院診斷符合率]

Clinical and pathological Dx concur[臨床與病理診斷符合率]

Pre- and post-operative Dx concur [術前術后診斷符合率]

Dx determined with in 24 hours (3 days) afteradmission[入院后24小時(3 天)內確診]

Discharge status[出院狀況]

recovered[治愈]

improved[好轉]

not improved[未愈]

died [死亡]

Dispositon[去向]

home[家]

against medical ad[自動出院]

autosy[尸檢]

transferred to[轉院到]

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