病歷紀錄原則

黃瑞仁
臺大醫院雲林分院院長
台大醫學院內科教授

1
 為什麼要寫病歷？
•醫師的工作記錄。
•是病患病情記載唯一的文字資料。
•知道診斷的心路歷程及治療的計畫，作為學
習、研究和教學的參考。
•醫師法的規定。
•醫療糾紛時判斷責任時的參考依據。
 病歷紀錄
• 病歷書寫的內容是醫療品質、教育與研究
的重點
• 病人就醫過程記錄
– 醫護人員對病人的評估、治療計畫與執行
– 交班記錄
– 給藥記錄、手術記錄、侵襲性與高風險檢查或治療記
錄
– 醫囑與前後病情變化的關聯性和連貫性
– 記錄時間點正確性
– 記錄者簽章
3
 病歷紀錄
1. 用最熟悉的語言和文字
2. 如何整理事實
• 時間的記錄方法，敘述病史時間缺乏連貫
• 完整的症狀敘述
• 量化病人的症狀
• 勿擅自解釋病人症狀
• 記錄就醫過程
• 病人過去史和近況的記錄
用自己最熟悉的語言和文字
表達，避免辭不達意。(但
是目前規定要用英文書寫，
請用簡單清楚的文句）
 病例書寫的技巧
• 簡明達意
即用最精簡的文字、圖形，完整的描寫病
人診療的現象、過程，並正確表達意見。
 病歷最重要的原則
• 信: 就是真實
• 達: 就是清楚
• 雅: 就是文雅、有品味、不要反覆陳述
 病歷紀錄常見問題
• 病歷記錄書寫，如為電子化病歷，複
製情形嚴重 (Copy & Paste 的濫用)。
• 病歷記錄書寫內容不能恰當呈現病情
變化，與支持診斷或治療的決策。
• 醫護記錄不一致。
• 各級醫師病歷書寫方式格式不一致。

8
 病歷記錄原則之主要內容重點
•初診、急診與住院的記錄，一定要包含就診的具
體目的與理由。
•主訴是指這次生病的臨床表現或病徵及發(得)病
的時間。儘量以病人的陳述或表現來敘述，並避
免使用醫學專門用詞，更不必使用完整句型。
•病人若有昏迷、啞巴、口齒不清、幼兒、精神錯
亂、沉默、失語症、癡呆不能陳述時，以病人的
主要問題 (chief problems)、關切 (chief
concern)、臨床表現 (clinical presentation)
的標題來記述，並註明提供資料者。
門診病歷
急診病歷
住院病歷
• Admission note • Chief complaint • Medical orders
• Present illness • Consultation
• Progress note • Past history • Procedure notes
• Weekly • Personal History Conference note
summary • Family History • Operation note
• Review of systems • Anesthesia note
• On-service Note • Physical • Problem lists
• Off-service note examination • Psychosocial
• Lab findings evaluation
• Discharge • Medical imaging • Pain assessment
summary • Diagnosis • Nutritional
• Management plan assessment
• Signature
 基本資料
Name: 黃XX Age: 83 y/o Gender: male

Chart No: Bed No: 13B 12-1 Admission Date:

3xxxxx6 2009/08/12
Occupation: Marital Status:
Retired Married

要寫admission note完成的時間（西元年月日時分）
 Admission note 基本結構
1. Chief complaint 6. Physical examination
2. Patient history 7. 檢驗紀錄(Laboratory report)
Present illness 影像報告(Imaging report)
a) Past history: medical , 8. 診斷(Diagnosis) or
surgery, hospitalization, 臆斷(Tentative diagnosis)
allergy
9. 治療計畫(Plan of management
b) Current medications and treatment)
3. Family history 10. 出院規劃(Discharge Planning)
4. 社會心理相關評估
(Psychosocial assessment)
5. Review of systems

12
 Admission Note
• Basic Data
• Chief complaints
• Informant (patient or proxy)
• History of present illness including review of NTUH and
outside medical records when appropriate
• Past medical history (including allergy)
• TOCC (Travel, Occupation, Contact, Cluster)
• Past/current medications
• Birth history/maternal history/vaccination history/growth and
development (in pediatric patient)
• Family history
• Review of System
• Physical examinations
• Results of laboratory tests, and diagnostic imaging
• Tentative diagnosis
• Initial medical plan of care
– Diagnostic, Therapeutic, Educational
 主訴
• 主訴（Chief complaint）是病人問題的核心
• 盡量簡明扼要
• 包括主症狀（盡量”量化” ）及期間或
onset之時間
• 根據主訴，瞭解前因及後果，均列入
present illness
 Chief complaint
(Chief concern, Chief problem)

症狀加時間
• Intermittent severe right upper abdominal
pain for 6 hours.
• High fever up to 39.6 degree for 2 days.
• Sudden onset of severe chest pain for 30
minutes.
 主訴 ： 簡明扼要
• Fever up to 38.3 with chills since 8/8

說明: 改為 for X days

Fever up to 38.3 °C with chills for 2 days

(since 2009/8/8)
 現病況 Present illness
• Opening statement
• 完整描述病程及入院原因
• 發生主訴之前因後果、相關事件
• 注意時序關係
• 注意因果關係
• 符合邏輯與醫學知識
• 相關 versus 不相關

17
 現病況 Present illness
和present illness有關之past history 才寫在
present illness。

如懷疑pneumonia之患者可把DM寫入
present illness，因其可會增加pneumonia之
發生頻率及嚴重度。

但不要把hypertension，gout，benign
prostate hypertyophy全部寫入present illness.
18
 Present Illness（現在病史）
• 以主訴為中心，鋪陳發展。將主要問題，
依發生之先後次序敘述
– 重視變動之情形
– 就醫經過－包括檢查、治療、反應及重要之資
料、醫師的診斷等
 現在病史
•包括症狀的自然史與相關病史
–將問診的資料經過消化整理後以時序重點寫出。
–注意追蹤症狀的演變，不要只有檢查資訊。
–症狀描述時，加入鑑別診斷的資訊
– 小心分辨病人敘述的真實性或正確性
– 注意症狀”量”的觀念（即嚴重性）
•如過去病史，家族史或社會史如有相關， 應
該加入。
–如為多次入院，有豐富且密切相關的過去病史，
應將這些資料精要整理後置於第一段。
 OLD CARTS
O: onset
L: location
D: duration
C: character
A: aggravating / associated factors
R: relieving factors or radiation
T: timing of onset or temporal factors
S: severity of symptoms
 LQQ OPERA

 L: location (Right upper quadrant, RUQ)

 Q: quality (dull pain)
 Q: quantity (severe, barely tolerable)
 O: onset mode (after meal)
 P: precipitating factors
 E: exaggerating factors
 R: relieving factors (bending forward)
 A: accompanying symptoms (nausea)
•現病況 (present illness) 勿描述太多過
去病史或與現病無關的資料。不必列出過
去所有的疾病，主要記錄與現病有關的細
節、診斷與治療經過。
•各器官系統複查 (review of systems)，
原則上是補充現病歷或既往歷，為了避免
遺漏與現病史有關的事項，就身體的各部
位，進行系統性的調查事宜。
 Review of systems

• Ask and record common symptoms associated with each system

• 是history之一部份，你忘了問，患者忘了講的symptom，趁此在每個器官系統
把幾個重要之symptom問有或沒有。
• 要詳加描述
• 不可前後矛盾
• 有問才列出來
24
病人簡介(Introducing the Patient)
在寫主訴及現病歷之前，先簡介病人基本資料、病
人背景、生活史、身體狀況等。病歷資訊由病患本人提
供外，亦可由其家屬或照顧者陳述。

1) 職業
應具體寫出以前職業及現職，包括實際的工作性質、
業務場所、環境、人際關係、職業變更的理由，這些對
疾病發生或病因有潛在關係，極具參考價值。
2) 教育(education, schooling)
病人對病史的表達力、字彙、正確性及內容與教育程
度的高低有關。與病人溝通的話題或說明檢驗、治療
項目等，尤需考慮教育程度。

3) 婚姻(marital status)
結婚幾年、配偶年齡、未婚、離婚、同居、鰥、寡等。
撫養眷屬數目與關係，協助了解家庭經濟之收入來源與
所得程度。

4) 居住環境(home environment)
獨居、與家屬居住、或家屬住附近。所居住的是公寓、
大廈、樓層高或低，與照顧者或鄰居的關係。住家附近
的生活機能。
5) 嗜好(hobbies) 、日常活動(daily activities)
如喜歡看電視、釣魚、爬山、聊天等，主要在了解病人日
常生活的品質及自行活動能力的程度。

6) 習慣(habits)
喝酒(哪一種酒?) 、抽菸、檳榔、咖啡、茶、藥物等每天
的量，以及飲食、睡眠(午覺)及其他特殊生活習慣，戒菸、
戒酒的理由，以及特殊餐飲與健康服藥的關係

7) 社交活動(social activities) 、宗教(religion)

了解病人的症狀、疾病與特殊文化或與社會的互動關係，
信教的動機與虔誠的程度。宗教影響生活、飲食、禁忌、
戒律、治療、檢查等。
8) 旅遊史(travel history)
病人曾去過或來自傳染病疫區(epidemic area)或某區域
的地方性疾病(endemic disease) ，曾在當地飲食、衛
生環境、接觸過的人是否有類似的疾病，藉以了解發燒
的病因及可能感染的途徑

9) 擅長之語言(language)
以病人使用最擅長之語言陳述。若是透過翻譯或者無法
直接溝通等，需加以註明。

10)資訊提供者(source of information)
為了解詳細病情及病史的可靠性，需要提供看護或照護
者的資料。
 家族史Family history
• 至少三代 Died of
CVA at 65
y/o

asthma DM

31
[護理協助初始評估] 注意完整性，如有空白或不完整，請自行補齊或待護
理評估完成重新帶入

有關初始評估

32
•身體診查 (physical examination)，如有不
能做或需較多時間執行時，建議診查之前，先
敘述病人的狀態，如病人昏迷，無法反應或痛
苦等狀況提供說明。
•記錄身體診查 (physical examination) 之方
法，使用統一格式或列出與現病有關的部分，
或以發現異常為主來記載。
•出院摘要 (discharge summary)，以簡潔記錄
從住院到出院與病情有關的重要診療資料。
 Physical Examination
•記得要記錄重要之生命現象，不要忘記記錄 BP
•重要器官要 inspection, palpation, percussion,
和 auscultation。
•紀錄及描述陽性發現及重要之陰性結果(important
negative findings)。不要利用格式化紀錄如(+)(-)
或只寫normal。
•可繪圖更清楚
•肛診檢查
•神經學檢查
•病人拒受診查要特別註明
•病人因意識不清或其它原因無法完成身體診查需註明
34
35
POMR

POMR
醫師書寫病歷採問題導向的病歷書寫方式(POMR)
為原則

問題導向的病歷由四部份構成構成：
1.資料庫(database)
2.問題列表(problem list)
3.初步計畫 (initial plan)
4.病程記錄 (progress note)

37
 Problem-Oriented Medical Record (POMR)

• Lawrence L. Weed (1964)

• 以問題(problem)為中心之病例書寫，住院時把所
有之問題列出。
• 再針對每一問題，給予初步評估分析及提出治療
計畫(包括診斷，治療，及衛教計畫)
• 每日之progress note亦是針對每一問題給予評估
分析及後續之處理計畫

38
 POMR四個基本階段(Weed)

Database Problem list

#1…
History
#2…
Physical examination #3…
Laboratory data ….

Initial plan Progress note

#1: #1:
S:
Plan: diagnostic, therapeutic
O:
educational A:
#2: P:
#2:
Plan:
S:
#3: O:
Plan
39
 POMR+SOAP
• 問題未標準化
• S/O
– 可能會重複
– 有些S/O無法包括於抽出的問題
– 有些問題沒有S/O (如輕度之hypokalemia)
– S/O未能呈現病人的治療過程
• A常被寫為診斷或鑑別診斷，與P重複
• 太強調記錄的形式，病人的資料被分割，沒有完整概念
• 像圖書館作業(資料儲存與獲取)，無法呈現臨床思路

• 太多paper work，費時間; 病歷記載比床邊的醫療與看護受

到重視
40
住院診療計畫
Problem list
1. Disturbance of consciousness most likely due to drug overdosage
2. Major depression
3. Fever due to aspiration pneumonia

Assessment and Plan:

1. Disturbance of consciousness most likely due to drug overdosage
- Keep adequate hydration
- Withdraw the suspected overdose oral drug
- NPO temporarily
- Check ABG, and blood chemistry profiles
2. Major depression
- Withdraw the anti-depression drug temporarily when drug overdosage is ascertained.
3. Fever due to aspiration pneumonia
- Keep current Abx use with cefoxitin 1 g q8h
Plan沒有按diagnostic,
therapeutic, educational
初步住院的診療計畫及住院病情說明，已向病患或家屬說明 書寫

主治醫師: 住院醫師: 護理人員:

41
42
43
 Modified POMR四個階段
Database Problem list
History #1…
Physical examination #2…
Laboratory data #3…
….
Initial plan
Progress note
S
#1: O
A/P
Assessment
#1:
Plan A:

#2: P:
#2:
Assessment A:
P:
Plan:

44
 Assessment and plan

• 病例若只有紀錄患者之病情，就無法知曉診治醫
師對於病情邏輯思考，鑑別診斷，對病情進展之
看法，及後續之治療計畫。因此assessment及
plan相當重要。
• progress note必須要呈現醫師對於病情與治療反
應的評估（assessment），以支持病程中診療計
畫（plan）

45
主訴(Chief Complaint)
Yellowish skin discoloration for about 1 month

病史(Brief History)
This 60-year-old businessman had considered himself well until 2 months ago,
when he began to feel unduly tired after busy work. Since then, he has taken
Herbalife(養生茶) to promote his health condition. About 1 month ago, he began to
notice tea-colored urine. One week later, he had an episode of chills and high
fever followed by general malaise, weakness, and poor appetite. There was no
nausea, vomiting, abdominal pain or diarrhea. He visited a private clinic, where
the doctor gave him some medications. Fever subsided soon, however, yellowish
discoloration and itching of the skin ensued. He has lost 5 kg of weight in the past
4 months and came to our outpatient clinic on Aug. 9th. He denied clay-colored
stool passage. Lab data showed direct-type hyperbilirubinemia and elevated ALP
level (T-Bil/D-Bil 7.93/5.94 mg/dL; ALP 931 IU/L). AST and ALT levels were slightly
elevated. Abdominal echo disclosed dilatation of common bile duct (CBD) and
bilateral intrahepatic ducts (IHD). Under the tentative diagnosis of obstructive
jaundice, he was admitted to our ward for further investigations and management.

46
治療計畫(Plan of Diagnosis and Treatment)

#Obstructive jaundice, cause to be determined

S: Mild itching of the skin

O: Icteric sclera
Abdomen: soft, no tenderness, normoactive bowel sound
Skin: yellowish discoloration
T-Bil/D-Bil, 7.93/5.94 mg/dL; AST/ALT, 65/74 IU/L; ALP, 931 IU/L

A: Hyperbilirubinemia, direct type

Elevated ALP and elevated AST/ALT, subsequent to cholestasis-related
hyperbilirubinemia
Abdominal echo showed dilatation of CBD and bilateral IHDs
No visible CBD stone or tumor mass
Weight loss in the past 4 months
-> Obstructive jaundice is most likely. Differential diagnosis includes CBD stone or
periampullary tumor (eg. Tumor of CBD, Ampulla of Vater tumor).

P: 1. Arrange MRI, including Magnetic Resonance Cholangiopancreatography

(MRCP), for further evaluation
2. Further therapeutic planning: Endoscopic Retrograde
47
cholangiopancreatography (ERCP) for brushing cytology or stenting
 Admission note: Assessment and plan for
each problem
Problem1: pneumonia
Assessment:
Patient has suffered from fever, cough with purulent
sputum for several days. Laboratory results showed
leukocytosis shifting to the left and CXR revealed a left
lower lobe consolidation. Left lower lobe pneumonia is
considered, and the most likely pathogen is
Pneumoncoccus or K. pneumoniae because the patient has
DM history.
Plan:
Diagnostic: blood culture, sputum culture for CAB XI, sputum smear and culture , for AFB
XIII, urine Pneumococcal antigen, urine Legionella antigen, Mycoplasma antibody
titer.
Therapeutic: O2 with nasal cannula 2 L/min, Amplicillin + sulbactam 1.5g IV g8h, IV and
roxithromycin 150mg po q12h, mucolytics.
Educational: use bedside toilet, keep on O2 treatment.
48
• Problem 2: DM
Assessment: DM for 6 years with regular medication and fair
control

Plan:
Diagnostic: check 4-section blood glucose and HbA1C
Therapeutic: keep on glibenclamide and adjust the dosage
according to blood glucose level
Educational: contact dietitian for education on DM control

49
 Assessment and plan- admission note

• Admission note中，各個問題之assessment主要是
1. 將病史，身體診查及實驗室檢查作一個簡單之
summary
2. 為何你認為患者有此問題
3. 並做鑑別診斷

• Plan要詳細，要分diagnostic, therapeutic, and

educational plan順序書寫。

50
 Progress Note (NTUH)
• 每筆Progress Note均需記錄日期時分
• Progress Note建議改以PAP(Problem-Assessment-
Plan)格式書寫
– 一個problem寫一個PAP
– Assessment: 包括SOAP的SOA，併為一項方行
便彈性書寫
– 依病程進展，每天應有不同之A、P；要能充份
表現 decision making 的過程和理由，尤其是重
要檢查、高貴藥物、抗生素等。

51
Progress note，重點在Assessment
• A：assessment包括診斷 ，鑑別診斷，診斷
依據，評估指標，及病情評估
– 醫師依據病人symptom/sign改變、檢驗結果作
為依據，寫出對於病情變化，以及治療反應的判
斷
– 呈現醫師的評估與決策判斷過程
– 是看出醫師能力、與呈現醫療品質最核心重要的
部分
– 讓病歷記錄對學習及診療真的有幫忙，而不是只
有一個形式
52
 Assessment
• 不能只寫診斷（因為診斷可能在problem已
經寫了），要加上對於診斷過程，以及處
置的必要描述，
• 再說明病情變化的判斷，以帶出後續的診
斷或治療計畫
• 所有的診療決策，都可在此找到原因
• 不是只有寫問題(診斷)之名稱!!

53
 Plan
• Plan:
– Diagnostic plan: 後續要做的檢驗，診斷程序
– Therapeutic plan：治療計畫（藥物、手術）
– Educational plan： 衛教計畫（糖尿病的自我
監測、臥床病人的家屬照護）

– 住院admission note的P以這種方式書寫為佳
（較完整），但是progress note依病情需要書
寫，不一定三種計畫都要列出，只需擇要書寫
54
 PAP
• Problem
–Assessment
• 含括S/O/A，不需制式書寫，比較靈活
• 紀錄每天對病人的觀察（症狀、身體
診查與檢驗結果），診斷，處置與評
估結果
• 要能呈現處方（如抗生素劑量調整）
或處置（如安排CXR，CT）的理由
–Plan
55
 Progress Note (day 3)
#1 Liver abscess
A: Third day of Rocephin 2g IV qd, Metronidazole 500mg
IV q8h. RUQ pain resolved (pain score = 1, no need of
analgesics). No fever, vital signs stable, blood culture grew
K. pneumoniae. WBC decreased from 15x109 /L
(admission) to 9x109/L (today). Clinical condition improving.
P:
1. Keep Rocephin 2g IV qd, Metronidazole 500mg IV q8h
2. GI specialist suggest ERCP after defervescence and
completion of antibiotic treatment
3. Consult ID specialist for duration of antibiotic therapy
4. Follow image study 3 days later, if fever flares up,
consider abscess drainage. 56
 Progress Note (day 4)
#2 DM
A: Blood glucose dropped from 335 on admission,
to 122 today; the initial high blood glucose level is
possibly due to infection. Currently under control
with glibenclamide 5 mg bid, effective control of
infections with antibiotics.
P:
1. Keep glibenclamide 5 mg bid
2. Dietitian will educate the patient about DM
control this afternoon
57
 Progress Note (day 4)
#1 Lung cancer, T1aN0M0, after VATS RUL
lobectomy on 2010-3-4
A: post-operative day 3, wound pain (score 2)
under acetaminophen, chest tube drain amount
less than 100 ml, start oral intake and incentive
spirometry
P:
1. Keep acetaminophen
2. Follow-up CXR, remove chest tube if lung
expansion is good.
3. Prepare for discharge after removal of chest
tube.
58
59
 <Progress note>
57 y/o woman with Date: 2010/08/17
1. Right lower lung nodule, nature to be determined Time: 15:30
2. Diabetes mellitus, type 2

<Active problems>
#1. Right lower lung nodule, nature to be determined
S: Persistent dry cough
O: Afebrile, stable vital signs
Fair appetite and psychosocial activity
Neck: soft, no lymphadenopathy
Chest: clear breathing sound, no wheezing, no crackle
Abdomen: oval and soft, normoactive bowel sound
<Lab data>
WBC 6530, Hb 13.5, Plt 284 x 103
PT 10.2, INR 0.93, Cr 0.8, BUN 12

60
A: Based on the low dose chest CT findings (a 1.6 cm lobulated nodule with pleural traction) and
her clinical presentation, the most likely diagnosis is lung cancer. However, some atypical
infections such as Cryptococcus infection or pulmonary TB were also considered to be possible.
Therefore, contrast CT study/CT-guided biopsy and microbiology examination are required for
further confirmation.

Plan:
1. Arrange CT scans of the brain, chest and abdomen with/without contrast
2. Consult radiologist for CT-guided biopsy
3. Bacterial culture, acid fast stain and TB culture of the sputum
4. Check cryptococcal antigen for possible cryptococcus infection

#2. Diabetes mellitus, type 2

A: Under OHA (metformin 500mg tid) treatment, her fasting blood glucose is 130 mg/dL and
HbA 1C is 6.8%. No proteinuria in the urine. She does not have blurred vision or limb
numbness.
P: 1. Keep DM diet
2. Metformin (500mg) 1# tid PO and regular monitoring of blood glucose levels
3. Consult a dietitian for providing patient education of DM control

61
 Progress note書寫常見之錯誤
•沒有分開對每一個problem寫assessment和plan
•Assessment沒有記載此問題今天之診斷治療進展如
何？變好或變壞？或有新的確定診斷，只有寫診斷
•Plan沒有依diagnostic ,therapeutic ,and educational 順
序書寫
•問題之號碼隨意改變
•已穩定之problem仍每天寫A/P
•新發生之問題沒有依順序編碼書寫

62
 Weekly Summary
• Weekly Summary在週末前填寫。幫助值班
醫師了解病情以及日後整理discharge
summary方便
• 內容應該含：
– 病人何時住院
– 住院的主要問題是什麼
– 過去一週做了什麼處置（包括重要檢查）
– 簡述病情及治療反應
– 下週的計畫是什麼
• 不是將admission note COPY過來
63
Weekly summary

字很多，因為
帶入冗長的
copy-paste段
落，即失去意
義，因為沒有
人會看，而且
跟上週的
summary可能
只差一點點
64
64
 Weekly summary (NTUH)
• 建議寫法
– Brief summary
• 簡單描述診斷與本週發生哪些事，作了哪些處理，
以及目前的狀況
– Active problem(s) and plan(s)
• 目前 active problem 及 plan
• 以 plan 為主，寫下後續的診療計畫，不需強調
assessment
– Current medications
• 整理目前使用藥物（提醒 order renew）

65
 Weekly summary
(2010-1-3~2010-1-8)
• 80-year-old man, admitted on 2010-1-3 because of tarry stool.
Endoscopy revealed active bleeding from duodenal ulcer. After
giving packed RBC transfusion and PPI, tarry stool stopped. Oral
intake started on 1/7
• Problem:
– #1 Duodenal ulcer bleeding
• A total 6 units of packed RBC were given. Hb increased from
8.5 to 11 g/dL. Losec was switched to oral Takepron 30 mg
qd since 1/7. General condition is stable
• He will be discharged before next Wednesday (1/13) if
condition unchanged. Follow up at GI clinic after discharge.
• Current medication
– Takepron 30 mg qd

66
 Weekly Summary
2010.8.20 11:15 (From 0814 to 0820, 2010)

This 48 y/o man with

1. Septic shock due to Gram-negative bacteremia, probably related to spontaneous bacteremic
peritonitis (SBP)
2. Acute liver decompensation, due to acute exacerbation of chronic HBV infection, or caused
by drug-induced hepatotoxicity associated with hepatic encephalopathy and coagulopathy
3. Elevated pancreatic enzyme, cause to be determined
4. Conjunctivitis, ou
5. Rheumatoid arthritis

<Brief history>
The patient was admitted for treatment of acute liver decompensation due to acute exacerbation of
chronic Hepatitis B virus infection or drug-induced hepatotoxicity. In this week,
esophagogastroduodenoscopy (EGD) for the pre-transplantation evaluation on 8/16 showed F1-2
esophageal varices formation without red-color sign. Propranolol was added for primary prevention
of variceal bleeding. On the 3rd day of the treatment, he developed high fever with chills in the
afternoon of 8/18. Tazocin was started after completing septic work-up. Septic shock occurred on
8/19. Aggressive IVF challenge and self-pay Albumin supplementation were given. The preliminary
blood culture yielded 2 sets of Gram-negative bacteria growth. Ascites routine showed increased
PMN count (360/μL). SBP was considered. Although urine output increased gradually, relative
hypotension (BP, 90~100/40-50 mmHg) persisted after IVF challenge. CVC was inserted for close
observation of hemodynamic changes and Levophed was also given for maintaining adequate BP.
His hemodynamic status has steadily improved thereafter.

67
<Active problems and Plans>

#1. Septic shock due to Gram-negative bacteremia, probably related to SBP

1. Keep Tazocin and pursue culture result
2. Close monitoring of hemodynamic status and urine output
Taper inotropic agent if feasible
3. Self-pay albumin supplementation
4. Daily monitoring of body weight so as to avoid fluid overloading

#2. Flare-up of HBV infection with liver decompensation (hyperbilirubinemia and

coagulopathy)
1. Keep entecavir use; regular follow-up of liver function profile
Inform the patient and his family about the possibility of deteriorating liver function
due to ongoing sepsis
2. Keep lactulose and maintain defecation 2-4 times per day to avoid hepatic
encephalopathy
3. Evaluate the suitability for liver transplantation
4. FFP transfusion p.r.n. if bleeding diathesis exists

<Current medications>
Tazocin 4000mg q6h IV
Levophed 5μg/min with titration
B.C 1 #qd
Entecavir (0.5mg) 1#qd ac
URSO (100mg) 1#tid
Lactulose 30ml tid
Gascon (40mg) 1#tid pc;
Takepron (30mg) 1#qd ac
Tinten 1# q6h prn if fever > 38.0℃ 68
 Weekly Summary 常見之錯誤

•太長之brief summary，把admission note

也整個copy and paste進來 (X)
• 請參考 previous admission note; refer
to previous medical record (X)

69
 On and off service notes
• 基本內容應包含
– 住院原因、重要發現、任何已做出的診斷、已做過的
處置、藥物治療以及其他治療、病情現況
• 建議比照 weekly summary
– Brief summary
– Active problems and plans
– Current medications
• On service note與off service note 不能一模一樣
– 轉床間的on service note建議可寫上「請參考off
service note」，另加上轉入時的PE及治療計畫
70
 <Off service note>
Date: 2010/7/31
This 56-year-old woman has Time: 17:30
1. Right lung tumor, nature to be determined
2. Hypertension
3. Dyslipidemia

<Brief history>
This 56-year-old woman with one month history of dry cough was
noted to have a huge mass in chest x-ray film at our outpatient
clinic. She was admitted for further investigation on 7/28.

<Treatment course>
After admission, chest and brain CT on 7/28 showed a large
lobulated lung tumor (6.0 cm) at the RUL involving the right hilum
and the central perihilar regions of the RML and the RLL. There was
no evidence of brain or skull metastasis. Bronchoscopy on 7/30
revealed external compression of RB2 and RB3 bronchi with nearly
total obstruction. EBUS-driven transbronchial biopsy was done for
tissue diagnosis, however, some blood-tinged sputum was noted
after the procedure. IV transamin was given for hemostasis.

71
<Active problem>
#1.Right lung tumor s/p EBUS-driven transbronchial biopsy
complicated with mild hemoptysis
Plan: 1. Observe respiratory pattern and vital signs
2. Pursue the result of bronchial washing and pathology report
3. Bone scanning will be performed on 8/2
4. Keep IV transamin if hemoptysis persists
<Current medications>
藥名 劑量 單位 頻率 途徑
Lipitor 1 tab qn PO
(Atorvastatin)
10mg/tab
Enalatec 1 tab qd PO
(Enalapril)
20mg/tab
Cough Mixture 10 ml q12h prn PO
(Cough Mixture
120ml/btl)
Tranexamic 1 vial q6h IV
Acid (針
Transamin inj
1000 mg/10
ml/amp)

72
 <On service note>
Date: 2010/08/01
Time: 08:30
This 56-year-old woman with
1. Right lung tumor, nature to be determined
2. Hypertension
3. Dyslipidemia

<Brief summary>
This 56-year-old woman with 1-month history of dry cough was noted to
have a huge mass on chest x-ray film at our outpatient clinic. Chest and brain
CT on 7/28 showed a large lobulated lung tumor (6.0 cm) at the RUL
involving the right hilum and the central perihilar regions of the RML and the
RLL. There was no evidence of brain or skull metastasis. Bronchoscopy on
7/30 revealed external compression of RB2 and RB3 bronchi with nearly total
obstruction of the lumen. EBUS-driven transbronchial biopsy was done for
tissue diagnosis. Some blood-tinged sputum was noted after the procedure,
which has been successfully treated with IV transamin.

73
 <Active problem>
#1. Right lung tumor, s/p EBUS-driven transbronchial biopsy complicated
by mild hemoptysis
A: No more hemoptysis and no other physical discomfort now
<Physical examination>
Stable vital signs. Clear breathing sound bilaterally, no wheezing, no crackle.
Regular heart beat without murmur.
<lmage>

Chest x-ray film on 7/30 after post-transbronchial biopsy showed no evidence of

pneumothorax or exacerbation of right upper lung lesion. Hemoptysis stopped after
IV transamin.

Plans: 1. Observe respiratory pattern and vital signs

2. Pursue the result of bronchial washing and pathology report
3. Bone scanning on 8/2
4. Consider tapering off IV transamin if no more hemoptysis occurs
74
 病歷書寫規範建議 (NTUH)
• Admission note: Initial plan以POMR-SOAP方
式書寫為原則。
• Progress note：以PAP（problem, assessment,
plan）方式書寫，著重assessment。
• Weekly summary：以diagnosis，brief history
（當週內），active problem and plan（以plan
為主，少寫A），current medications分段書寫。
• On/off service note: off service note類似weekly
summary。on service note內容以承接照護時
的PE及後續治療計畫為主，history直接寫「請
參考off service note」。
75
 Discharge Summary (NTUH規範)
• 病史規範與admission note同
• 住院治療經過（course and treatment）內
容要詳實記載本次住院所接受之檢查、處置
與發生事件
• 出院病摘身體診查狀況改變需有記錄，沒有
改變就寫no change
• Lab 及 Imaging findings 摘要記載
• 出院用藥內容需註明藥品種類及劑量、用法
• 出院指示內容需完整（應包括後續追蹤、飲
食、傷口照顧、復健等）
76
 其它病歷應注意的地方
•勿使用不適當的符號及縮寫（入院與出院
病摘診斷勿使用縮寫）
– 例如，AAD 需改為 discharge AMA (Against
Medical Advice)、MBD 請改為 discharge
today (時間)
– 避免使用 Do、Ditto
• 病歷紀錄修改，應於被修改處劃線，並於
更正處蓋章或簽名加註日期，不得使用修
正液
77
 優良的病歷紀錄
• 完整的(complete)
• 正確的(accurate)
• 易了解的(comprehensible)
• 前後一貫的(consistent)
• 適時的(timely)
• 整合的(integrated)
• 合法的(legal)
 病歷記載原則

• 符合規定→不要偷懶
• 簡單精要→不找麻煩

• 絕對不要COPY-PASTE!

79
 病歷記錄通則:
日期、時間的記錄(Dates and Time)
• 為了配合國際，及各醫療機構間資訊交流
的方便，建議統一使用公元(The Common
Era; 與西元The Christian Era同義) ，以避
免混亂。
(一)日期(Date)
東方人習慣由大至小(年、月、日) ，西方人則由小
至大(日、月、年) 。

• 公元2009年8月19日有下列寫法: 2009/8/19；2009-08-19；
09-8-19；August 19，2009(美式) ；19 August 2009(英式)

時間的縮寫(abbreviated dates)
• 公元2004年6月2日 →2004-06-02(或’04-6-2, ‘04/6/2)
• 11月5日至11月11日→11-05~11(或11-5~11, ‘ 11/5~11)
(二)時間
• 12小時制(12-hour system)
• 24小時制(24-hour system)
近年來已廣泛採用既簡單又方便，更普遍
獲國際認同的24小時(24-hour system)來記
載時間，不必分上午、下午。各列出二位
數字，中間以“：”分開，或兩者連一起
時前面加at。
24小時制(24-hour system)
• 上午9點31分(9:31AM) →09:31(或at 0931)
• 中午(noon) →12:00
• 凌晨、上午0點18分→00:18(或at 0018)
• 下午4點5分→16:05(或at 1605)
 年齡的寫法(Age of Person)
• 病人現在幾歲
 The patient is 64 year old.

 The patient is 59 years of age.

 The patient is a 56-year-old man (woman).

• 以年齡做為形容詞置於病人之前(幾歲的病人)
 This 33-year-old patient, …

• 以年齡置於病人之後
 A young man aged 24(years)
 年齡的寫法(Age of Person)
• 幾歲時(或以來，之前)的病情、病史、健康狀態
 The patient had pneumonia at the age of 12(years)
 She has had hypertension since the age of 56.

• 未滿一歲嬰兒使用週(日)記載比較簡明、方便
 如3個月8天的嬰兒以14週(aged 14 weeks, 14-week-old)表
示。

• 在簡要病史記錄上可使用短片語
 Diabetes since age 45
 Head control at 3 months (of age)
性別的寫法(Gender Reference)
(一)男性、女性
1. 生物學上，性別分為male(雄性)與female(雌性) ，
在人類也可以用來表示男性、女性。但醫學上診療
對象是人，不應以一般生物用詞(雄、雌)來表示男、
女。

2. 成人男女應使用man, woman;如：
 This 45-year-old man with a history of…
 This 56-year-old woman presented with…
3. 兒童及青少年則使用boy, girl；如：
 A previously healthy 8-year-old girl began to
have…
 This 11-year-old schoolboy complained of…

4. 胎兒、新生兒、嬰兒則可用male, female
 A 3-week-old female neonate
 A 9-month-old male infant
 A female baby aged 4 months
(二) 基本資料欄、表格、摘要的性別記載
在病人資料欄、表格、證明書，不管年齡都可以使用male (M)
男 女
或female(F)來表示男、女的性別特徵。 字譯
actor actress 演員
職業上的性別 businesswoman 實業家
(三) businessman
Waiter waitress 服務生
簡寫、縮寫及簡稱(Abbreviations,
Acronyms)
醫護人員慣用醫界人看得懂的縮寫，但同一簡稱，
在不同的領域有不同的詞意，也有醫師不依簡寫的原
則。自創簡寫或縮寫，因此醫界都呼籲儘量不使用簡
寫、縮寫，也免誤解。現強調病歷要大家都看得懂時，
建議在第一次出現時寫出全名，後面以括弧註明簡稱。
 病歷記載使用的時態
(Verb Tenses in Medical Record)

病歷記載使用的時態，應以寫紀錄的時
期來設定基準時點，再視前後時間關係做明
確的一貫時態。
(一) 現病史、既往歷、家族史、個人史(history taking)

1. 過去式(past tense)
發病前的狀態、發病時的情況、過去就醫情形、誘
因等，皆為這次就醫、問診之前的事情，應使用過
去式。

 The patient had a high fever 3 days ago.

 The patient was transferred to our hospital yesterday.
2. 過去完成式(past perfect tense)
表示過去的某一件事之前的情況、經過；常與過去
式時態使用於同一句子中，敘述發病之前的狀態、
過程，並強調前後時間的關係。

 Before she became totally blind, she had complained of

explosive headache and nuchal pain for 3 days.
 The patient had been well until 6 days ago when he
began to complain of severe headache.
3. 現在完成式(present perfect tense)
表示發病以後至現在的經過、經驗、已經完成的事
情，或一直持續到現在的症狀、狀態、病情、習慣。
(常與for, since, never, always, already, before等介
系詞片或副詞連用) 。

 The patient’s diabetes has been well controlled.

 The patient has had repeated sprains of the ankles since
his childhood.
4. 現在式(present tense)
表示現在的症狀、職業、習慣、處境、生活型式、
想法、感受等。

 He thinks he has no illness.

 The patient makes frequent business trips to Mainland
China.
(二)身體診查(physical examination)
診查所見的記載，通常使用現在式時態。

• 病程紀錄(progress note)
簡記(brief clinical note) ，護理紀錄(nursing record)
等不必以完整的文章記述。也可省略冠詞及動詞。

• 在討論會、學會、醫學雜誌上，以病例報告陳述個
案時，因為診查、檢查結果資料已過時，通常使用
過去式。
 處方與治療(Prescription and
Treatment)
(一)使用主詞與不同語態動詞的文例

1. 醫師(我們)給病人吃藥。
 The doctor (we) administered the drug to the
patient.(主動語態)
 The drug was administered to the patient.(被動語態)

不可說成The patient was administered with the drug.

2. 醫師為了治療症狀/疾病給予病人藥劑

 The doctor gave the patient the drug for treatment of

symptom/disease.
(以醫師為主詞的主動語態)

 The drug was given (to the patient) for treatment of

symptom/disease.
(以藥劑為主詞的被動語態)

 The patient was given the drug for treatment of

symptom/disease.
(以病人為主詞的被動語態)
3. 症狀/疾病/病人以某特定藥劑治療。

 The symptom/disease/patient was treated with the drug.

(治療的對象為主詞的被動語態)

 The drug was used to treat the symptom/disease/patient.

(以藥劑為主詞的被動語態)

 The patient was treated with the drug for the symptom/disease.treated
with the drug for the symptom/disease.(以病人為主詞的被動語態)

 The doctor treated the symptom/disease/patient with the drug.

(以醫師為主詞的主動語態)

 The doctor used the drug to treat the symptom/disease/patient. (以醫

師為主詞的主動語態)
4. 病人服藥

 The patient took (received) the drug.

(主動語態)

 The drug was taken (received) by the patient.

(被動語態)
(二)處方、治療文例

 The patient received heparin to maintain partial

thromboplastin time (PTT) below 45 seconds.

 Iron replacement therapy was given for her iron

deficiency anemia.

 Asthma, treated intermittently with a budesonide

nebulizer, had begun 20years before.
(三)處方用詞縮寫
1. 投與方法的縮寫

口服 PO per os
皮下注射 SC subcutaneous
皮下肌肉 IM intramuscular
靜脈內 IV intravenous
關節囊內 IB intrabursal
關節內 IA intraarticular
脊髓腔內 IT intrathecal
腹腔內 IP intraperitoneal
舌下 SL sublingual
2. 投與時間的縮寫

1天1次 qd quaque die once a day

1天4次 qid quarter in die four times a day

隔日 qod quaque altera die every other day

每天2次 bid bis in die twice a day

一天3次 tid ter in die three times a day

有必要的時候 prn pro re nata as needed

睡前 hs hora somni before sleep

飯前 ac ante cibum before a meal
飯後 pc post cibun after a meal
立刻 stat statim at once
隨時 ad lib ad libitum as desired

照指示 ut diet ut dictum as directed

3. 單位的縮寫

公升 L liter

分升 dL deciliter

毫升 mL milliliter

克 g gram

公斤 kg kilogram

毫克 mg milligram

微克 mcg microgram (=mg)

單位 U unit

國際單位 IU international unit

百萬單位 MU mega unit (106)

4. 劑型(Form/Presentation)
tab = tablet 錠劑
inj = injectution 注射劑
cap = capsule 膠囊

amp = ampoule (英式) (安瓶)，ampule (美式)

soln = solusion 溶液
susp = suspension 懸浮液

gtt = guttae (英語drops滴，拉丁語gutta之複數型)

syr = syrup 糖漿
supp = suppository 栓劑
oral soln = oral solution 口服液
gel = gel 乳膠液
gran = granules 顆粒劑
vial = vial 小瓶
oint = oinment 油膏
cream = cream 乳脂、面霜
plaster = plaster 膏劑
btl = bottle 瓶
 度量衡(Units and Systems of
Measurse
(ㄧ)度量衡使用趨勢- 採用國際單位制(International
System of Units，縮寫SI單位)

• 1977年世界衛生組織(WHO)建議國劑科學界採用SI單
位，從此全世界有許多生物醫界刊物以採用國際單位
為優先測量單位。1986年美國醫學會雜誌(JAMA)提
倡採用SI單位後，美國領導生物醫學刊物已經體認SI
單位的重要性，而改SI單位。
(二)使用SI的優點及正確使用法

1. 以既定單位更大或更小的數量，SI單位制系以標準的字
首表達，一般使用字首代表103或10-3的倍數。
0.048mL→45μL；17500g→17.5kg

2. 字首與單位符號之間不加空隔，並以印刷體書寫，如ng、
kV、mJ或MN。字首與單位符號要統一縮寫或者統一逐
字拼出字母，如kV或kilovolt。 另外字首一定要和單位
一起使用，不可單獨使用，如106/s(每秒100萬次)不可
以寫成M/s。
3. 溶液之化學物質、檢驗或藥物濃度的單位以SI單位
的克分子濃度單位mol/ L來表示，不使用重量(質量)
或毫克(g)當量或重量/容液量(milliequivalent, mEq) 。

4. 但有些單位以非SI單位來表示
 溫度: ℃
 壓力: mmHg(毫米汞柱) 、mmH2O(毫米水柱)
 pH
 時間: min、h、d
(三)度量衡單位記號(units and symbols)
1. 長度(length)

nanometer 奈米 nm 10-9

micrometer 微米 μm 10-6

millimeter 毫米 mm 10-3

10-2
centimeter 釐米 cm

meter 米，公尺 m 1

103
kilometer 公里，千米 km
2.重量 （mass, weight)

picogram (皮克pg） 10-12

nanogram (奈克ng) 10-9
microgram (微克ug) 10-6
milligram (毫克mg) 10-3
gram (克g) 1
kilogram (公斤，千克kg) 10

3.容量 （capacity)

milliliter (毫升ml) 10-3

deciliter 10-1
liter 1
1ml = 1 cc (西西 cubic centimeter)
1 dL = 100 cc = 10 ml
1 L = 1000 cc = 10 ml

4.分子量 （質量）（amount of
substance)

picomole （皮莫耳pmol ,10-12 mole）

nanomole （奈莫耳 nmol, 10-9 mole）
micromole （微莫耳umol, 10-6 mole）
millimole （毫莫耳mmol, 10-3 mole）
mole （莫耳、摩爾、克分子、mol、1mole）
5.面積（area）

square millimeter （平方毫米 sq mm = mm2）

square centimeter （平方厘米 sq cm, cm2 )
square meter （平方米、平方公尺 sq m, m2 )

6.體積 (volume)

cubic millimeter （平方毫米 cu mm, mm3 )

cubic centimeter （立方厘米，立方公分、西西 cu cm, cm3 )
cubic meter （立方米，立方公尺 cu m, m3 )

7.時間單位（time）

millisecond （毫秒， msec, ms ）

second （秒，sec, s ）
minute （分 min）
hour （小時 h, hr ）
day （日 d）
week （週 wk ）
month （月 mo ）
year （年 yr ）