衛生福利部豐原醫院病歷書寫規範1050601更新

衛生福利部豐原醫院
病歷書寫規範
105年5月修訂
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目錄
壹、病歷記載原則與編排次序
一、病歷記載原則
二、病歷管理工作細則
三、病歷編排次序
貳、病歷書寫標準
一、病歷書寫基本格式
(一) 基本資料（Basicinformation）
(二) 主訴（Chief Complaints）
(三) 現在病史（History of Present Illness）
(四) 過去病史（Past History）
(五) 社會史（Social History）
(六) 家族史（Family History）
(七) 體檢發現（Physical Examination）
(八) 檢查記錄（Laboratory Examination）
(九) 診斷評估（Assessment）
(十) 治療計劃（Plan）
(十一) 簽名（Signature）
(十二) 複診病人相關病史（History on Return Patients）
二、怎樣寫好病歷
(一) 必需寫好病歷的理由
(二) 病歷應記載那些內容
(三) 應該怎樣寫好病歷
三、病歷書寫要點
(一) 病歷封面
(二) 門診病歷
(三) 急診病歷
(四) 住院病歷
1. 量的審查
2. 質的審查
(五) 衛生福利部豐原醫院電腦化出院病歷摘要製點
參、病歷書寫實例
一、入院紀錄
〈一〉內科實例
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〈二〉外科實例
〈三〉小兒科實例
〈四〉婦產科實例
〈五〉骨科實例
〈六〉泌尿科實例
〈七〉復健科實例
〈八〉耳鼻喉科實例
二、出院病歷
三、手術紀錄
〈一〉外科實例
〈二〉婦產科實例
〈三〉骨科實例
〈四〉泌尿科實例
〈五〉耳鼻喉科實例
四、本院常見英文縮寫
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肆、衛生福利部豐原醫院病歷管理規章
一、衛生福利部豐原醫院病歷委員會設置要點
二、衛生福利部豐原醫院病歷品質審查及獎懲作業要點
三、衛生福利部豐原醫院病房病歷管理要點
四、衛生福利部豐原醫院病歷借閱管理規則
五、衛生福利部豐原醫院病歷摘要、影本發給要點
六、病歷資料之提供
伍、病歷管理有關法令
陸、病歷資料之保密性
一、相關之法令
二、保密切結書
柒、疑似性侵害暨家暴病歷處理
捌、附錄
一、衛生福利部豐原醫院病歷審查表（量的審查）
二、衛生福利部豐原醫院住院病歷記錄品質審查表（質的審查）
三、病歷遺失請示單
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壹、病歷記載原則及編排次序
一、病歷記載原則
第一條：目的
為使本院病歷管理作業有所遵循，並提供臨床及學術教育所需研究資料，特訂定本準
則。
第二條：適用範圍
凡有關病歷之建立、審查、表單整理、保管、病歷分類統計、調閱、複印對外提供病歷摘要
以及診斷書、證明書之發給等事項均依本準則之規定辦理。
第三條：病歷建立
一、每一病患之病歷限為一份，如發現有兩份以上之病歷時，應合併於之後建立之病歷；
但如其中一份以上病歷有住院記錄時，則應合併於最先有住院記錄之病歷，若兩次皆
有住院紀錄，則應合併於有多次或最後有住院紀錄之病歷。
二、「病歷封面」之病患基本資料應依「初診資料表」建立，病患姓名、出生日期、性別等資
料如須更改時，應依據病患出示之法定證明文件辦理，證明文件並應置於病歷內保存。
第四條：病歷記錄
一、住院病歷紀應由病患之診治醫師負責，並應將(一)住院通知單(二)入院紀錄(三)醫
囑單(四)手術紀錄(五)出院病歷摘要(六)出院診斷(七)病程紀錄等資料填炙並簽章，
以求病歷之完整，若由實習醫師填寫時，需由住院醫師以上各級醫師核簽，住院及出
院病歷摘要、出院診斷、手術紀錄應由主治醫師核簽。
二、門、急診病歷紀錄
(一) 初診病人：必需要填寫門診初診病歷
(二) 複診病人：要紀錄主訴，必要之理學檢查，及所申請的檢驗項目。前次之檢驗結果
若有異常者，應紀錄於病歷。久未看診者，或未看診本科者，應以初診病歷方式記載
詳實。
(三) 如為慢性病患，病情穩定，取前次相同之藥者，「病況穩定」(Condition Stable)
或類似子句為之。
(四) 用藥必需與所紀錄之事項符合，劑量亦須註明。
(五) 切忌處方之外，一切空白。
(六) 處方完後要簽章(字體清晰，能辨認者始可)
三、其他病歷紀錄表單之填寫另訂之。
第五條：紀錄注意事項
一、病歷紀錄須內容清楚，文字整潔。
二、醫囑不得塗改，如已開立而必須取消時，應簽名負責。
三、「入、出院診斷」「手術前後診斷及術式」不得使用縮寫。
四、每張病歷表單均標示病患姓名與病歷號碼。
五、填寫病歷均應註記時間。
第六條：病歷完成時限管制
一、住院病歷紀錄應於病患出院7日內(含假日)內成。
二、急診病歷紀錄應於病患離院翌日(逢假日則順延)上午九時前完成，並送達病歷室。
第七條：病歷審查
一、量之審查，由病歷室依「未完成病歷審查之項目」審查之。
二、質之審查由病歷管理委員會依「病歷質之審查表」審查，並將改進要點及評分結果，
提醫務會議檢討改進。
第八條：未完成病歷罰扣規定
一、未完成病係指病歷紀錄內容未完備，不合乎本準則第四條及第五條所規定者。
二、未完成病歷如逾期未完成者，依病歷審查要點罰扣辦法辦理。
第九條：病歷表單設計
一、新設病歷表單或病歷表單修訂時，均應送病歷管理委員會審查通過後始得使用，病
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歷室發現有未經病歷管理委員會審查通過之新設或修訂表單時，
應即轉送病歷管理委員會處理。
二、病歷表格尺寸分三種：
(一) 病歷封面：21.9 X 27.8cm
(二) 大張病歷表單(二號紙、報告表(即需打孔裝訂者))：21.6 X 27.5cm。
(三) 打洞：二個洞孔間距74mm，洞孔直徑7mm。洞與左紙邊距7mm，洞與上邊距
98(95)mm，與下邊距95(93)mm。
(四) 邊線：大張表單即21.6 X 27.5cm，其左邊線至左紙邊距24.9mm，右邊線至右紙邊
距6mm，底邊線至底紙邊距12mm，上邊線至上紙邊距23mm。
第十條：病歷整理
一、病患之病歷均應設置「病歷封面」。病歷記錄應將住院病歷按住院次序置放於最前面，
餘按病患前來門診、急診之時間先後順序排列。
二、病歷整理方式另訂病歷整理作業規範遵循之。排列方式參考住院病歷表單排列順序
表。
三、存入病歷之紀錄及表單均應以正本為原則，但經病歷管理委員會審查同意之圖表及
照片等得以影本存入。
第十一條：病歷保管
一、病歷由病歷室負責總保管，但看診或住院期間、由該單位負責保管保密。
二、死亡病歷、不活動病歷及超厚病歷得全部或部份抽調另行單獨存放。
第十二條：住院疾病分類、統計
疾病分類人員應將住院病患所罹患之疾病及接受之手術，按照國際疾病分類(ICD-
10-CM/PCS)所編定之系統予以分類編號及登入電腦，並統計彙編。
第十三條：院內之病歷借閱，應依本院頒訂之「病歷借閱則辦理」。
第十四條：法院調借病歷
一、法院因案以公函調借病患病歷時，本院應配合提供，但病歷出借時，應會知原診治
醫師。
二、出借病歷應以影本行之，但若法院要求必須提供病歷正本者，則應留存影本。
第十五條：保險公司洽詢病歷
保險公司洽詢病歷紀錄應以公函為之，並檢附病患同意書，本院始得受理。
第十六條：病歷摘要及影本之提供
一、轉介之病患離院時，診治醫師不得拒絕填寫病歷摘要。
二、複印病歷應依病歷複製本流程辦理。
三、病患本人、病患之配偶，法定代理人及病患委任之第三人(除本人外需有委託書)得
申請複印病患之病歷摘要。
四、病患申請病歷影本應依民國九十三年四月二十八日公佈修正醫療法之規定辦理。
五、其他醫療院所要求提供病患之病歷紀錄時，診治醫師得依照本條二至四之規定辦理。
第十七條：診斷書及證明書之發給
一、醫師開立診斷書時，先核對患者之證件且應將開立日期、診斷書類別、診斷內容及醫
囑等資料紀錄於病歷上。
二、若本人無法前來時，應填妥委託書連同證件正本交與受託人，開立時，先核對患者
證件及受託人證件。
第十八條：教學研究病歷
具有教學研究之病歷及相關資料應妥善保存並做註記。
第十九條：遺失處理
一、借閱之病歷遺失時，病歷室應促請借閱人填具「病歷遺失切結書」。
二、若法院遺失調借之病歷正本時，應促其出具遺失之證明。
第二十條：實施與修改
本準則經醫務會議通過後實施，修改時亦同。
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三、病歷管理工作細則
一、有關門診及住院病歷之檢調整理、遞送、歸檔事項。
二、有關病歷量的審查事項。
三、有關住院索引、手術索引及其他相關資料之製作及整理事項。
四、有關各類報告單之簽收、整理粘貼事項。
五、有關病歷借閱管理事項。
六、有關新病歷製作事項。
七、有關門診掛號事項。
八、有關指導學生實習及考評事項。
九、有關病歷之研究改進及臨時交辦事項。
十、癌症登記事項。
十一、死亡登記事項。
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三、病歷編排次序
〈一〉病歷編排之首要原則為按事件發生時間的先後排序。
〈二〉門診、急診、住院病歷應按時間先後做區段性連續排置，不做個別分開存放。但任何二者之銜
接即為一個區段的結束。例：病人門診多次後辦住院，出院後繼續在門診治療多次後又掛
急診，之後再繼續於門診治療，則此個案之病歷編排區段有五段，圖示於下：
住院病歷
門診病歷
急診病歷
其他表格單張
大張報告單
小張報告黏貼單
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病歷編排原則及排列順序
一、以事件發生的時間順序為排列的依據，唯住院病歷排列於門、急診病歷前。
二、門診病歷排列順序
1.門診病歷封面
2.門診初診病歷
3.病歷二號紙 (眼科、婦產依日期排序，中醫、牙科接二號紙後獨立放)
4.癌症病人病情告知說明單
5.急診病歷 (另有急診排序)
6.癌症治療計劃書、放射腫瘤科癌症登記資料表、血液腫瘤診斷檢核表、肝癌診療檢核表
(BCLC)癌症分期
7.門診注射聯黏貼單
8.產前記錄單 (最後置於該次生產住院記錄之住院許可證前)
9.門診手術記錄單(麻醉、手術前後交班記錄、手術護理記錄、手術自願書及麻醉自願書)
10.排尿日誌
11.門診注射護理記錄
12.各類檢查同意書(依相同表單之時序排列)
13.轉診單、他院摘要
14.各科大張檢查報告單
15.檢驗報告粘貼紙
三、出院病歷表排列順序
1.出院診斷單張(第一次住院時需置放或前一張已填滿)
2.病歷摘要
3.出院照護衛教及後續照護治療計畫書
4.Admission Note
5.Progress Note(病歷二號紙填寫)
6.全人整合照護記錄
7.健保雲端藥歷查詢結果
8.存留導尿單 (貼於二號紙)
9.會診單-急診會診單不放住院病歷
10.麻醉記錄(ANESTHESIA RECORD)
11.手術前後交班記錄
12.手術記錄
13.手術前後 X 光影像圖
14.手術室護理記錄
15.手術後麻醉恢復室記錄
麻醉液體平衡記錄表
CVC Cardiac Surgery Weaning Record
心臟血管外科體外循環記錄單
16.手術前訪視單(105.1)
17.麻醉前評估調查表
18.麻醉術前評估&計畫
19.分娩記錄
20.產程記錄
21.產後護理記錄
22.ICU 轉入、24 小時、轉出評估表
加護病房 TIMI SOCRE 評估紀錄
23.轉介病歷摘要
24.參考文獻
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25.外傷嚴重程度(ISS)評分表
26.他院之病歷摘要或報告單
27. Rt-PA 治療急缺血性腦中風
輸血反應探討單
28.各科特殊表單及各科大張檢驗報告單 (全民健康保險心導管檢查申報表)
29.小張報告粘貼單
30.出生證明 (婦產科)
31.管制性抗生素使用申請單(留感控有回覆那份)
32.成人 TPN 處方箋
化療藥物醫師手打(寫)醫囑單
化學治療藥物外滲追蹤紀錄表
癌症治療副作用評估表
化學治療醫囑暨給藥紀錄單(一律貼在空白洞洞紙)
33.UD 總表
34.長期醫囑單
35.臨時醫囑單
36.病患自控式止痛法使用麻醉藥品醫囑單
37.體溫表
38.投藥與治療單
39.吩坦尼穿皮貼片劑使用紀錄表
40.監護記錄
41.ICU 治療記錄
42.Neurological Record
43.血壓脈博呼吸和瞳孔記錄
44.呼吸治療紀錄
45.胰島素注射部位記錄單
46.輸入和輸出記錄單
47.患者翻身記錄單
48.營養照護記錄
49.營養評估暨療程進展表
50.安寧共同照護表
51.安寧共同照護其他專業人員訪視表
52.復健治療訓練記錄表單
53.床邊復健治療記錄表
54.社會工作照會單
55.排尿日誌 (間質性膀胱炎初診單，照日期放門診部分)
56.藥事照顧記錄表
57.藥劑科巡房記錄表
58.□護理之家□居家護理□日間照護轉介單
59.加護病房病患身體評估紀錄單
60.住院病人約束記錄單.
61.壓瘡或傷口紀錄表
62.護理指導紀錄單
63.衛生福利部豐醫院護理摘要紀錄單
64.手術全期護理記錄單
65.臨床路徑護理錄表
66.轉床護理交班紀錄
67.衛生福利部急診照護摘要交班記錄單
68.心導管檢查/治療紀錄交班單
69.高級心臟救命術(ACLS)
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70.護理記錄
71.新生兒護理記錄
72.護理計劃表、復健科住院計劃書
73.ICU 護理評估表、其他護理評估表，跌倒危險因子評估表，壓瘡高危險群病人評估表，
安寧病床持續疼痛評估表、初步疼痛評估表、持續疼痛評估表、中心導管每日照護評估表&
中心導管置放檢查表
74.出院計劃及護理指導
75.手術自願書、麻醉自願書(照順序)
76.自費同意書、其他相關同意書、CT 檢查說明書(含侵入性診療流程檢核表-同意書之後)
77.自願退院書
78.住院診療計畫說明書、加護病房診療計畫說明書
79.死亡證明診斷書
80.入院許可證 (癌症病人病情告知說明單)
※因各科護理處置單不同若有其他單張，請置放於投藥記錄及護理記錄中，但需依相同之單張依
序排列
四、精神科急性病患病歷排列順序
五、若有新增其他科別及護理治療單位，依照相同表格日期發生順序依序排列在投藥紀錄與
護理紀錄中間。
六、住院中病歷排序
1.不施行心肺復甦同意書
2.跌倒危險因子評估表、壓瘡高危險群病人評估表
3.外傷嚴重程度(ISS)評分表
4.出院準備服務初篩表
5.住院診療計畫說明書
生命徵象隔板之後
6.體溫表
7.Neurological Record
8.血壓脈博呼吸和瞳孔記錄
9.輸入和輸出記錄單
醫囑單隔板之後
10.長期醫囑單
11.臨時醫囑單
12.病患自控式止痛法使用麻醉藥品醫囑單
病歷紀錄隔板之後
13.出院診斷單張(第一次住院時需置放或前一張已填滿)
14.病歷摘要
15.出院照護衛教及後續照護治療計畫書
16.Admission Note
17.Progress Note
18.全人整合照護記錄
19.存留導尿單
20.他院之病歷摘要或報告單
21.ICU 轉入、24H、轉出評估表
手術紀錄隔板之後
22.麻醉紀錄(ANESTHESIA RECORD)
23.手術前後交班記錄
24.手術紀錄
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25.手術前後 X 光影像圖
26.手術室護理記錄
27.手術後麻醉恢復室記錄
28.麻醉前評估調查表
29.麻醉術前評估&計畫
30.手術全期護理記錄單
31.心導管檢查/治療紀錄交班單
32.分娩記錄(婦產科)
33.產程記錄(婦產科)
會診紀錄隔板之後
34.會診單-急診會診單不放住院病歷
35.營養照護記錄
各科檢查隔板之後
36.各科特殊表單及各科大張檢驗報告單
檢查報告隔板之後
37.小張報告黏貼單
38.出生證明(婦產科)
39.管制性抗生素使用審查單
護理記錄隔板之後
40.轉床護理交班紀錄
41.衛生福利部急診照護摘要交班紀錄單
42.護理記錄
43.新生兒護理記錄
44.護理計劃表、復健科住院計劃書
45.ICU 護理評估表、其他護理評估表
其他表單隔板之後
46.入院許可
同意書隔板之後
47.手術自願書、麻醉自願書(照順序)
48.自費同意書、其他相關同意書
49.急診病歷
七、急診病歷排序順序
1. 急診病歷
2. 委外救護車(小張的，貼在急診病歷後面)
3. 急診護理評估表
4. 護理紀錄
5. 照片(急診已另外貼好於牛皮紙上)
6. 約束探視紀錄單
7. 急診照護摘要交班紀錄單(若為 AAD，未收住院)
8. 高級心臟救命術(ACLS)紀錄
9. 外傷小組啟動/啟動及評估紀錄 (未收住院)
10. 全人整合會議紀錄 (未收住院)
11. 會診單
12. Rt-PA 治療急缺血性腦中風 (急診做歸急診，住院中歸住院)
13. 大張報告單，如大張心電圖、腹超…等。(不含小張檢驗單)
12
14. 發燒篩檢
15. 緊急輸血照會單
16. 同意書(侵入→輸血→約束→自費)
17. 自願退院書(AAD)
18. 轉院風險告知書
19. 緊急傷患轉診單(外院轉入)
20. 轉診救護紀錄表(外院轉入) 例如東勢農民醫院轉診救護紀錄
21. 緊急傷患轉診單(白色)
22. 救護紀錄單(紅色)
備註：
1. 當次急診整份用釘書機訂起來。
2. 唯有 CT 同意書與門診 CT 同意書放在一起。
小張檢驗單黏貼於最後與門診檢驗報告(牛皮紙)在一起
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貳、病歷書寫標準
一、病歷書寫基本格式
FORM OF CLINICAL HISTORY
AND
RECORD OF PHYSICAL EXAMINATION
It is generally recongnized that one of the most important function of a

hospital is to maintain records from its clinic and house patients.
The record should be sufficiently accurate and complete to lead itself to

future research and it is a legal document with regard to the hospital's
action in a given case.
The purpose of the history is to record an intelligent, logical and

sequential story of the development of the patient's illness. When complete,
it should give a clear picture not only of the disease
but also of the patient as an individual.

〈一〉BASIC INFORMATION
1.Administrative Data
Usually obtained by O.P.D. or ward clerk; check for completeness and supply
missing data. Should include full name, age, sex, race, domicile, date of
birth, occupation, home address,marital status, next of kin 〈including name,
address, and phone number〉, date of admission and admission number to hospital
record library.
2.Date Present History Obtained
3.Source of Present History
The source of history and its reliability should be stated, including
whether information was obtained from the patient, member of his family,
previous records of the hospital, records of other hospital, or communications
from outside physicians. If obtained from individual other than patient, or if
apparently incomplete or unreliable, state reason.
〈二〉CHIEF COMPLAINTS
The symptom or situation which is the reason for seeking medical aid.
State the complaints in single descriptive 〈in so far as possible, not
14
diagnostic〉 word or phrase in patient's own language with
duration. For example:
1. Gas in abdomen, 2wks.;
2. Constipation, 2yrs.
These words, however, should contain a clear expression of thought and not
vague phrases such as "heart trouble" or "kidney trouble".
〈三〉HISTORY OF PRESENT ILLNESS
All historical materials directly referable to the cause, onset, course
and treatment of the patient's illness, no matter where obtained in course of
eliciting history, should be complied into a detailed, orderly chronologic
presentation.
The onset should be dated as accurately as possible.
The term referring to time, such as "two weeks before admission", may be
used but should be supplemented by their dates. Do not use the days of the
week.
When mentioning symptoms, record an accurate description of each,
including time, mode of onset, severity, duration,location, character and
relation to normal activity such as effect of posture, movement, respiration,
eating and bowel movements.

Further important information, including symptoms which the patient forgot
to mention, will often be obtained from the past history, especially from the
systemic review. However, if this information pertains directly to the present
illness, it should be recorded under that heading.
〈四〉PAST HISTORY
1. General Health
Give the patient's impression of his physical states through life,
including school and work record, previous physical examinations and
examinations for life insurance, if any. State the greatest weight, average
weight, present weight and weight gain or loss if any with duration.
2. Previous Disease
Record according to patient's age at the time. Note details of major ones.
Special attention should be paid to those which might have a bearing on the
present illness and describe details concerning their course, severity,
duration, treatment and squelae.
It must be emphasized that to name a disorder and accept "yes" or "no" is

often insufficient; it is advisible to identify the disease for the patient by
describing common sysmptoms and signs.
3. Vaccinations and Sera 〈Dates〉

4. Previous Hospitalizations and Operations
Record date, symptoms, diagnosis,treatment, name of doctor and hospital.
15
State all operative procedures and note details of major
ones. Mention any x-ray, radiotherapy or biopsies.
5. Accidents or Injuries
Note details of major ones and residual disabilities if any.
6. Be sure to record any drug sensitivity, including inquiry about
penicillin and sulfonamides.
12. Neuro-Muscular System
Metal status and the ability to deal with daily activities, headache and other
cervico-cranial pain, diplopia, dysarthria. dizziness, drop attack, syncope or
fainting, facial numbness, ataxia 〈trunk and limb〉,involuntary movements,
transient deficits of muscle power, sensation and vision 〈amaurosis fugax〉
involuntary movement, weakness of limbs, intermittent claudication, sphincter
control.
This form is merely a guide and is not designed to be used to fill in
answers to specific questions.
〈六〉SOCIAL HISTORY
1、Occupation, past and present, nature and hours of work, amount of
tension, opportunities to dusts, chemicals and metals.
2、Education
3、Previous Residencies
4、Military Service
5、Marital History
Duration, whether happily married or not, age and health of spouse and
children.
6、Amount of sleep, exercise and time for recreation.
Use of tobacco, alcohol, tea, coffee and drugs.---Give quantity of
these as nearly as possible, e.g. 6 to 12 cigarettes a day; tea 10 cups a day.
〈七〉FAMILY HISTORY
State health and age of father, mother, brothers, and sisters; if
deceased,age and cause and previous major illness, temperament of
parents;incidenceofcancer,diabetes,tuberculosis,bleeding,arthritis,hypertensio
n, heart disease, nephritis, nervous disease and allergy.
〈八〉PHYSICAL EXAMINATION
When recording negative findings, don't make sweeping statements such
as "heart negative". Avoid use of the words "negative"and"normal".
1. General appearance
Each physical examination should begin with temperature, pulse,
respiration, blood pressure 〈state arm and position〉.Height and weight should
also be included. This may be obtained from nurses' notes. Development,
apparent nutritional status, habitus, apparent age compared with actual.
16
Mention the state of health 〈acutely or chronically ill,
dyspneic, cyanotic etc.〉. If the patient is ambulatory, the
posture should be noted. Note the mental state, if any changes 〈such as
unconsciousness, ill-orientation, abnormal attitude, reaction to examination
or unusual facial expression〉. Personality status, with reference to mood,
coorporation, general intelligence etc. Speech: if abnormal.
2. Skin
Describe texture, moisture, temperature, eruptions, pigmentation,
jaundice, hemorrhage, scars, edema, sign of weight loss, distribution of
hair, and nails.
3. Lymph Nodes
Record size, tenderness, consistency, mobility and whether discrete
or matted. Examination should include lymph nodes in the maxillary, submental,
cervical, supraclavicular, axillary and inguinal regions and, when indicated,
epitrochlear, other groups such as the femoral, popliteal etc.
4. Head
Skull：
Note symmetry, irregularities, tenderness, scars and bruits,
including palpation and percussion, when indicated, over sinuses and mastoid.
Eyes：
Describe prominence and intraocular movements, lid-lag, nystagmus,
isual fields, visual acuity, color and vascularity of sclerae and
conjunctivae, and cornea.
Pupils---Note shape, regularity, equality, reaction to light and in
accomodation.
Fundi 〈Ophthalmoscopic examination〉---Mention the condition of
vessels, disc, retina and media.

Ears：
Show gross orientation of hearing 〈when indicated, distance at which
is audible, Rinne and Weber tests〉.
External ears 〈Otoscopic〉---Canals, drums and discharge.
Nose：
List septa1 deviation, condition of mucosa, obstruction and
discharge.
Mouth and Throat：
Describe breath if abnormal 〈fetor oris, acetone oder, uriniferous
oder, cholemic breath etc.〉 ; oral hygine; lips,teeth,gingivae and

tongue 〈moisture, protrusion, tremor and papillae, if abnormal〉.
Pharynx---discharge, palatal reflex; tonsils; character of voice,
if abnormal.
5. Neck
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Note stiffness.
Describe trachea 〈deviation or tug〉 and thyroid.
Cervical lymph
nodes and vessels 〈distention, pulsation〉 should be observed.
6. Breasts
Note presence of masses, tenderness or scars.
7. Thorax and Lungs
List symmetry, size, shape, expansion on both sides, depth and
character of respiration; tactile fremitus, percussion. Lower borders of lungs
with diaphragmatic excursions.
Under auscultation, include voice sounds and breath sounds with all
adventitious sounds fully described.
8. Cardio-Vascular System
Inspect and palpate the precordium for unusual activity, including
accurate localization of the apex impulse. Thrust, thrill or heave
should be noted.
Percuss the heart borders and look for retromanubrial dullness.
Record the area of precordial dullness in tabular form, indicating
distances in cm. from the midline.
Right Interspace Left

---------------------------------------------
2
---------------------------------------------
3
---------------------------------------------
4
---------------------------------------------
5
---------------------------------------------
The description of auscultation should include rate 〈with

comparisonof apical and radial rates〉 , rhythm, quality of sounds and
anyaccentuations 〈compare P2 with A2〉 , any cardiac murmurs with their punctum
maximum, pitch, quality, intensity, 〈Grade I-VI〉,timing and transmission. For
example:
〈1〉 Grade III apical pansystolic blowing murmur transmitted to

the axillary area.
〈2〉 Following loud opening snap, Gr. III apical middiastolic

rumbling murmur with presystolic accentuation.
〈3〉 Harsh rasping Gr. III systolic ejection murmur at aortic area
with transmission to right carotid artery.
18
Blood pressures---Comparison of the two arms where there
is any
difference in the strength of the radial pulses. Blood pressure in
lower extremities, when indicated.
Peripheral Vessels---Mention the character of vessel walls and
pulsations of the arteries: the carotid, the brachial, the radial, the
femoral, the popliteal, the posterior tibial, the dorsalis pedis arteries
and other vessel, if of interest, and should be record as follows if all
palpable.
C B R F P PT PD
L ++ ++ ++ ++ ++ ++ ++
R ++ ++ ++ ++ ++ ++ ++
Note the distension and abnormal pulsation of neck veins.
9. Abdomen
Inspection of contour, incisional scars, any venous engorgement
〈grade, distribution and direction of blood flow; if any〉 and any
obvious herniae should be made.
Palpation and perucssion of liver, including its upper border, and
palpation, for spleen, kidneys and urinary bladder.
When viscera are palpable, the size, the character of the surface and
edge should be described, including any tenderness and any
special features.
Note any tenderness, masses or spasm. Auscultate for peristaltic
sounds. Examine carefully inguinal rings for herniae in males and
observe any other herniae.
10. Genitalia
In male：
Note the unusual development of penis, phimosis, urethral discharge,
testes, epididymides and scrotum.
In female：
The patient should be draped to avoid unnecessary exposure. As a

means of supplying reassurance to the patient as well as offering legal
protection to the examining physician, the nurse remains inattendance after

preparing the patient for examination. Note the outlet, Bartholin's and
Skene's glands, urethra, cervix, fundus andadnexa.
11. Rectal Examination

Describe hemorrhoids, fistula, fissure, sphincter tonus, prostate,
19
appearance of stool on glove and masses, if any. Always do
test for occult blood on stool specimen on globe.
12. Locomotor system
Spine：
Note any abnormal curvature, tenderness, or other abnormalities.
Extremities：
Freely movable or not?
Joints：Note swelling, range of motion, heat,tenderness.
Note any clubbing, cyanosis, dependent edema, varicosities, ulcers,
etc.
13. Neurological Examinations
〈1〉General observations and consciousness
〈2〉Mental status
〈3〉The cranial nerves
〈4〉Motor function
〈5〉Involuntary movements
〈6〉Sensation examination
〈7〉Coordination and gait
Equilibrium
Non-equilibrium
〈8〉Sphincter and autonomic functions
〈九〉LABORATORY EXAMINATION
Laboratory examination of urine, blood, and stool must be completed
as quickly as possible.
Urinalysis：
Record color, pH, specific gravity, albumin, reduction 〈if reduction
is present, acetone and diacetic acid〉 , bilirubin, urobilinogen, and
complete microscopic examination of the sediment of a centrifuged specimen of
fresh urine.
Blood：
Include hemoglobin, red count, white count smear study differential
count, and sedimentation rate.
Stool：
The stool specimen obtained on the glove after rectal examination
may conveniently be used. Give gross description, test for occult blood
〈benzidine, guaiac orpyramidon.〉
Do microscopic examination for ova, parasites etc.Serological tests for
syphilis in all cases.
Chest X-ray：
An X-ray picture of the chest is required, in principle, for all
patients admitted to the hospital.
〈十〉ASSESSMENT
Write a definite diagnostic impression or list the "working"
diagnosisin the order of their importance and include pertinent
20
differential diagnosis---For example:
1. Gastric carcinoma 〈primary diagnosis〉 ,
R.O. gastric ulcer, peptic
2. Prostatic hypertrophy and
3. Senile cataracts.
〈十一〉PLAN
State what test you would run plan with purpose or reason and
whattreatment you recommend.
〈十二〉SIGNATURE
The name in Chinese and rank of the writer is to appear at the end
of the history, thus:
_______________________ Resident（R1,R2 or R3）
Histories written by clerks or interns must show the approval and
signature of the resident.
〈十四〉HISTORY ON RETURN PATIENTS
The past record should be obtained as soon as possible. If the
presentillness is obviously a continuation of the illness for which
the patienthad previously been admitted, an abstract of previous
admissions and significant clinical visits should be made, followed
by an interval history.
On the other hand, in some instances, examination of the past
record would add no significant information about the course of the
illness but would merely destroy the teaching value of the case for
the
clerk.In this event, the clerk should not examine the chart before
presentation on rounds.
附註：此章「病歷書寫基本格式」摘錄於台灣大學附設醫院病歷書寫規範
21
二、怎樣寫好病歷
〈一〉必需寫好病歷的理由
1. 病歷是重要的醫療記錄，是病患病情記載惟一的文字資料，也是醫師為病人服務的記載。
2. 必須清楚而且詳細記載，可以知道診斷的心路歷程及治療的計劃（Planning），可以作為學習、
研究及教學之參考。
3. 醫師法及醫療法均詳細規定，醫師有責任（義務）寫好病歷。
4. 醫療糾紛發生時，常是判斷責任問題時最重要的依據。
5. 醫師自己的工作記錄，應儘可能寫好記錄。
〈二〉病歷應記載那些內容
1、個人基本資料－病歷號碼、病人姓名（如果是外國人，應記載其發音）、性別、年齡、出生年月日
住址（包括現住址及戶籍所在地）、聯絡電話，以及緊急聯絡人。
2、病情經過－含現在病史、過去病史、家族史、個人史，旅遊史等，特別重視病情發展及治療經過
包括發病日期、症狀發生狀況及進展，醫師檢查及診斷，治療經過，特別是抗生素消炎劑止痛
藥，包括麻醉藥及一般止痛藥， Prednisolone 及其他 Steroidpreparation ，安定劑
Sedative、tranquilizer 及安眠藥以及經常服用之藥物，至少服用連續二週以上的藥物，另
外尚要記錄有無藥物過敏。
3、每次診療經過，無論是門診、急診及住院病人均需詳細記載，來診的原因，主要的症狀，最近
變化，以及診療結果，處理要點等。處理要點包括藥物、生活指示及有關治療的意見。
4、每次記載時應記錄檢查之結果，以及可能之診斷，並概略敘述鑑別診斷上之有關要點。
5、每次記錄時，應特別記錄診斷，尤其診斷更改時更要詳細記載更改之理由及主要之依據。
6、每次記錄時，有關之處理意見有所改變時，應特別記載，並敘述理由。
7、緊急狀況、意外，或特殊變化（病情突變、突發症狀），應記錄發生及記載之時間。
8、個人簽名（Signature）－原則上應簽中文全名或蓋章。
9、急診病歷應特別記載病情變化，特別是檢查結果，包括理學之變化，X 光及實驗室檢查結果，
每一次記載時均應填寫記錄之時間及姓名，並作好必要之交待。
10、住院病歷必需特別再增加的內容有五大項：
（1）住院病歷( Admission Note )
1.1 入院日期須填寫
1.2 住院紀錄之醫師簽名
1.3 由實習醫師填寫，住院醫師應予督導並簽核。
1.4 住院紀錄包含(13項)：
基本資料 Chief Complaint Present Illness Past History
Physicial
Social history Allergy History Family History
Examination
Review of systems Laboraroty data 精神層面入院診療計畫
Impression(Assessment)
（2）病程記錄（Progress Note）：
2.1每一天病情變化均應詳細記載，每天所作之檢查項目、結果等，均要詳細記載，如果
有主治醫師、主任、專家或他科會診，或討論會均必需記載主要的內容及結論，以備
22
往後之醫師瞭解。.
2.2 病患住院中之病歷記錄，逐日記錄，但病況不穩，可能依病情
隨時紀錄，記錄除了註明年月日之外，也要註明確實之時間
2.3 每日之病程記錄以P.O.M.R方式書寫，ICU每日記載2次，並加註時間點。
2.4 影像檢查結果，重要發現應繪圖
2.5 Assessment 不能只寫出住院時之impression而沒有評估
（3）交班記錄－包括交班摘要（Off Service Note）及接班摘要（On Service Note）：住院醫
師有時需要輪換，在交班之前原住院醫師應填寫交班摘要，記錄病人之重要診斷，主要治療
經過，主要問題，治療上之注意事項，以及展望以後之治療或病情發展。由於原住院醫師對
病人之瞭解比較深刻，由他記錄最為恰當，口頭交班常會忘記或忽略，有文字記載比較好，
而且也可以方便日後查閱。而接班的醫師，聽了前一住院醫師的報告之後，也看了Off
Service Note，再親自診察，一定對病人有相當之認識，再寫成之On Service Note 將可以
幫助自己瞭解病人，非常重要！也許瞭解得不夠深入，可以在往後之Week Summary 中再補充
（4）出院病歷摘要（Discharge Note）：
是對病人在院中診斷及治療之主要記錄,由於經過情形可能複雜，必須擇要敘述，其中最重
要的部份包括：
a.主要病狀
b.主要理學變化
c.主要檢驗，特別是有關診斷的主要根據
d.主要診斷及相關變化（如合併症，特殊全身狀態等）。
e .住院診療經過及特殊記載
f.出院應給予照護衛教及後續照護醫療計畫書
出院病歷需依規定儘早完成，並隨時可提供門診醫師參考，也可以提供病人出院後攜回備用。
（5）手術記錄（Operation Note）：
外科系病人，住院中常要接受手術，手術前後之診斷，手術時之發現，手術之主要程序，切
除那些器官都必需詳細敘述，而且要繪圖說明以幫助理解麻醉方式，有無引流管，若有應註
明型式、放置位置及手術後病人情況，當然手術時間、手術者及助手之姓名等必需記載。
〈三〉應該怎樣寫好病歷
1、病歷是事實之陳述，因此首一要求是事實。一般醫師都用英文書病歷，表達也許不能發揮
可以中文表示。很多精神科病人之敘述，常用中文表示更加傳神。
〈1〉LMD 或local hospital 無法確切明白是那一醫師或那一家醫院，不妨寫下XX 內科
（ＸＸ市ＸＸ路等），以方便與原診治醫師聯絡。
〈2〉病史，由病人敘述最為真實，但有時情況特殊，由親屬、同居者、朋友甚至發現之路人、
警察或陌生的旅館職員送到醫院，他們不一定瞭解病人之狀況，因此當病人無法自我
陳述時，一定要記述病史取自何人。
〈3〉有關現在病史之症狀，儘量記述發生之日期，急性症狀甚至要記載時刻，以便利鑑別
診斷，有關過去病史，儘量問出年、月。特殊事件，如闌尾炎手術，車禍發生日，住
院等大都會記得日期，應儘量追問後記載。
〈4〉手術、外傷、貧血、或出血（含各部位），均必需詢問有無輸血，並記入輸血量，可大
略得知出血之嚴重性。
〈5〉過去病史，有關診斷之詳情，應詳細追問，可瞭解其可靠性。
2、敘述要清楚。
對每一症狀都要敘述得清楚，包括症狀情形，嚴重性，發生時間，症狀期間及相關症狀等
都必須記載，而且各項症狀發生之前後順序及相關性也儘量列入，另外自症狀產生至來診期
間所有之變化（症狀加重、消失、或持續，或起伏不定），也需清楚陳述。
舉例說明如下：
Bloody Stool 或Anal Bleeding 事實上包括：
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a：fresh anal bleeding
b：Anal dripping
c：Diarrhea with bloody stool
d：Bloody mucoid stool
e：Bloody purulent mucoid stool
f：Dark bloody stool
g：Melena
應清楚記述出血量，鮮血便、暗紅血便、或黑紅色瀝青便........等。
3、記載要詳細、完整。
儘量列出病人過去健康上的問題及發生現在病史之診治經過。個史中記述。例如10 年前因為
潰瘍穿孔手術，最近一個月飢餓時胃痛，2 週前胃酸多，七天前吃感冒藥，三天前黑便，均應
一併記載，因為這些症狀均可能與本疾病有關。
4、自己最熟悉的語言及文字表達，可免辭不達意。
最好是以病人的口吻敘述，存真，最好不要自行詮釋，改用「自己認定」、
「專有名詞」，記
述病人之症狀。「腰酸背痛」用‘renal colic’；「大便變黑」用‘melena’不是好的表示法。
「大便變黑」,只是單純大便顏色黑，可能表示黑而硬，也可能黑而且很軟，半液態，意義截
然不同，但‘melena’只表示像瀝青狀之糞便，必是黑而且很軟，呈液態或半液態。「昏倒
了」，可能只是「頭昏昏的，跌倒在地」（但沒有失去知覺），也可能是「暈倒後暫時失去知
覺，但很快又醒來」，更可能是「倒下去後完全昏迷了」，如果一味用‘coma’或fainting’
也不能表示其真實情況。
5、結果之記載，要記述檢查日期及主要變化－即結果。
結果表示之意義－可能是診斷依據，以及對臨床之影響，可否解釋病情？是否已解決臨床問
題！當然這一結果是否可靠也可以表示意見。
檢查所見之內容應敘述，如是影像檢查應畫圖，如是數目字應寫出數字，如是普通檢查，可
以不必列出數字，如sugar、RBC等，如果是特別檢查，方法不同，結果也不同，因此單位要
特別寫出來，最好連正常值也列入參考，如：
Alkaline phosphatase,
BU 〈Bodansky unit, 2.4.5 BU〉，
KAU 〈King-Armstrong Unit, 1-13 KAU〉及
IU 〈International Unit, .100 IU〉。
6、特殊記載：
開刀記錄：一般用紅筆記載。特殊診查記載，如Cardiac Catheterization, Biopsy 診斷，
內視鏡，超音波，Angiography,Radiotherapy, CT 檢查、輸血、改換治療方針........等等
都必需清楚地標示及記述。
如果住院中發生意外（由床上跌倒、被刀割、發生昏迷現象，發生藥物反應........等）要特
別記錄發生之時間，而且在一次記述後，短時間（指3 小時以內），再作第二次敘述，並繼
續間斷記載，直到情況緩和。
7、一般而言，住院病人每天至少記述一次，加護病房至少2次。
但不要只記述Vital Sign，或一句話‘Stationary’，如真的不需記載，也應考慮出院。病
人即使無變化，也不應不記錄。
8、病歷記載要負責，因此一定要簽名，而且是簽全名。
有個人職章時可加蓋章，不可以只寫姓王，姓陳，簽名也不可以潦草，讓人不知是誰！
9、養成寫Summary Note 的習慣，住院超過7日應寫Weekly summary。
On Service Note,Off Service Note,Admission Summary 以及比較複雜多變化病例之
ClinicalSummary 或Summary Note 等，醫師應該養成記錄的習慣，對臨床經過方會經常檢
討！也敦促自己儘快建立確切診斷，以安排積極治療。
10、利用T.P.R. Sheet。
把主要的檢查（如 C.T, Angio CardiacCatheterization, Upper GI, Colonoscopy,
Bronchography, EEG......等）及主要之治療（如輸血、抗生素、化學療法、放射性治療、特殊
藥品治療......等），及重要處置(手術)均列於上面，使對臨床經過，有一目瞭然的效果。
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三、病歷書寫要點
〈一〉病歷封面
1. 基本資料之填寫
本院初診或電腦掛號作業推出以後不曾再來本院應診、電腦上尚未有資料之不活動病歷的病
人於掛號時，應填初診掛號資料單，基本資料包括：姓名、性別、出生年月日、戶籍所在地、通訊
地址、國民身分証字號、職業、電話、婚姻狀況、本院初診日期、聯絡人、旅遊史及過敏史。
2. 基本資料之建檔與確核
掛號人員受理掛號時應同時電腦建檔，為確保電腦資料之正確性，建檔人員應再核對一次。
3. 病人姓名之更改為確保病歷檔案管理之正確性，病人姓名不得任意塗改。
若病人確實已更名，且出示相關証明文件（例：有更名記錄的戶口謄本或身份證），在掛號
室修改電腦資料，應將文件副本送至病歷室黏貼。
4.歷次住院記要
若有住院事實則負責醫師需填明科部別、入出院日期、年齡、診斷及處置，並蓋章或簽名。
5. 藥物過敏史
由醫師註記藥物過敏，及過敏之藥物名稱，並簽名加註時間。
〈二〉門診病歷
1. 初診，依本院門診初診格式填寫
各科部之第一次門診或一種疾病之初發，應依S.O.A.P 要領填寫。因門診時間有限，病歷記
載應把握精簡扼要原則。
2. 複診
．記載追蹤情形，病情進步、退步或有任何變化都應詳實記錄。
．看診時檢查結果若已知曉，應記錄在病歷上。
．病人未親自前來應診，病歷上亦應註明。
〈三〉急診病歷
1. 採用急診病歷專用紙書寫。
2. 以S.O.A.P 要領填寫。
3. 病人處理後應有追蹤記錄。
4. 病人離院時要有離院狀況記錄，並註明醫囑指示。
〈四〉住院病歷
住院病歷之書寫應符合本院出院病歷審查標準。病歷審查有兩種：「量的審查」與「質的
審查」，前者由病歷室負責，後者由病歷管理委員會的委員擔任。
1. 量的審查
每本出院病歷由病歷室量審人員依「衛生福利部豐原醫院病歷審查表」作常規性逐項審查，審
查結果病歷記載內容未完整者，置於各醫師未完成病歷櫃裡，醫師應主動前往病歷室完成。未
完成病歷由電腦作追蹤列管，每月跑月報表及罰扣報表作為病歷書寫獎懲的資料。
本院為提昇病歷記錄品質，加強主治醫師對病歷審核督導職責，自主治醫師未核簽者，歸為
主
治醫師未完成病歷，並列入追蹤管理。主治醫師亦應主動前往病歷整理室完成。
以下就病歷審查表所列項目依序提示「量」的審查標準。審查項目有缺漏不全時，審查人員會在
審查表上打勾註記。
〈1〉 Diagnosis on face sheet（病歷封面上的診斷）應將出院診斷填寫於病歷封面上
〈2〉 Diagnosis on red sheet（住院病歷首頁上的診斷）應將入院診斷填寫於住院病歷首頁上
a. Identification data（病人的基本資料）
病人基本資料每一細項都要填，不可只填姓名及病歷號碼。
b. Provisional diagnosis（暫時診斷）入院時之暫時診斷不可簡寫或縮寫（ Do not

abbreviate）。
〈3〉 Discharge Summary（出院病歷摘要）
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84.4.1 起配合全民健保，推出病歷摘要電腦化作業，其製作
應依「衛生福利部豐原醫院電腦化出院病歷摘要製作要點」辦理。出
院診斷不可簡寫或縮寫（Do not abbreviate），也不可寫"Ditto"，"Do"或"同上"等，應
以完整的診斷名稱表示。若病人有做病理切片檢查，應參考病理報告後再做診斷。
〈4〉 Admission note（入院記錄）、Signature（簽名）
入院記錄應詳細填寫，記錄若由實習醫師填寫必須由住院醫師級以上的醫師複簽，簽全名
或簽名加蓋章。
〈5〉 Progress note（病程記錄）、Signature（簽名）
必須由住院醫師級以上的醫師簽全名，若由實習醫師記錄，住院醫師應予複簽後，主
治醫師座復核，修改或評論。
〈6〉 Special reports（特殊記錄單）
a. Laboratory（檢驗記錄）
Laboratory Examination Sheet 應詳實記錄
b. Obstetrical（產科）
以下記錄單視情況填寫，若無資料可填，則寫Nil 或NO。
．Labor & delivery finding（分娩記錄）
．Puerperium sheet（產褥期記錄）
c. Medical or Surgical（內科或外科）
Special drug on T.P.R. sheet
d. Operation note（手術記錄）
．凡是在手術室做的處置都應有手術記錄單。
．Identification data（病人基本資料）
．Operator（包括術者及助手）
．Anesthesia（麻醉方式）分局部、腰椎及全身三種。
．Diagnosis
pre-operation（術前診斷）
post-operation（術後診斷）
．Procedure（術式）
．Operation finding（手術發現）
．Operation procedure（手術過程）繪圖說明等。
．Signature（簽名）
〈7〉 Order sheet（醫囑單），醫師開立醫囑需簽名/蓋章，臨時醫囑於24小時內補簽/章。
a. Discharge order（出院醫囑）
應註明是經醫囑出院MBD（May Be Discharged）或違背醫囑出院AAD（Against Advice
Discharge）。
b. Consent to AAD（違背醫囑出院志願書）
若病人是違背醫囑出院，則病歷內必須有志願書，當病人要出院時，應留意志願書是否已附
在
病歷內。
〈8〉 Anesthesia report（麻醉記錄單）
a.凡是腰椎麻醉或全身麻醉的病人都應有麻醉記錄單。
b.Signature（簽名）指麻醉記錄單下方應有麻醉醫師簽全名或蓋章。
〈9〉診斷一致性的審查
＊下列診斷應一致，若有不一致時應詳閱病歷重新考慮：
Final diagnosis on face sheet（病歷封面上的出院診斷）
Discharge Diagnosis on discharge summary（出院病歷摘要上的出院診斷）
Diagnosis on operation note（post-operation）（手術記錄的術後診斷）
Diagnosis on pathology report（病理報告上的診斷）
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2. 質的審查
依照「衛生福利部豐原醫院病歷品質及獎懲作業要點」辦理，每2月由病歷
管理委員會之委員審查，依「衛生福利部豐原醫院住院病歷記錄品質審查表」作抽樣審查。
〈五〉衛生福利部豐原醫院電腦化出院病歷摘要製作要點
1. 病人的基本資料（Identification data）
應確核電腦化摘要上方所列印之病人基本資料是否正確無誤（尤其是入院及出院日期）。
2. 入、出院診斷（Admission diagnosis, Discharge diagnosis）
應將主要診斷列在第一項；若有次要診斷時，則列在第二項以後，所有次要診斷均應詳實列出切
勿遺漏。診斷不可簡寫或縮寫，也不可寫"Ditto", "Do"或"同上"等，應以完整的診斷名稱表示。
因同一種病灶若發生在不同部位，對其治療計劃或癒後會有很大影響，故完整之診斷應含部位之
描述，例：
〈1〉 Odontogenic keratocyst, ramus, mandible, left；
〈2〉 Abscess, submandibular space, right。
此外，若有檢查報告診斷或會診診斷，亦應一併列入。合併症與併發症均應詳實列出切勿遺漏。
3. 主訴（Chief complaint）
應採用病人自身的表達語句記載病患主觀的描述，選擇最重要的徵象來寫，簡明扼要，避免使用
診斷性醫學用語，並須提及疾病徵象的頻率與時間。
4. 病史（Brief history）
須描述病人症狀徵候的發生時間和種種跟此次住院病因有關的過去診斷治療經過，以及與現況的
關係。
5. 體檢發現（Physical examination）
包括視診、聽診、叩診和觸診等之記錄。
6. 手術日期、方法及所見（Operation）
若有手術，則須繕打手術術式、手術日期及手術重要發現，其內容應與手術記錄單吻合。
7. 住院治療經過（Course and treatment）
簡要描述住院後所作之重要處置及病況改變情形。
8. 合併症（Complication）
簡要描述住院後才發展出來的疾病狀況。所有併發症都要寫出，不要遺漏，並請列入出院診斷項
目內做為次要診斷。
9. 檢查記錄（Laboratory）
〈1〉一般檢查：如CBC, BCS, EKG.....等常規性的檢查項目。
〈2〉特殊檢查：各科部專有的特殊檢查項目，如EEG.......等等。
10. 放射線報告（Radiology）如：CXR, CT.....等等之報告。
11. 病理報告及解剖所見（Pathology）
若有病理檢查或解剖，應列印出結果，並應與出院診斷一致。
12. 出院時情況（Discharge status）
電腦螢幕上有：治癒出院、繼續住院、改門診治療、死亡、病危自動出院、非病危自動出院、轉院、
身份變更、潛逃、自殺、其他、轉部、改善等項目，可依需要點選。
13. 出院指示與用藥（Recommendations & Medications）
需鍵入出院後之計劃，如：門診追蹤及用藥情形等。
14. 簽名（Signature）
必須由住院醫師級以上的醫師簽全名或蓋章，住院醫師簽章後應由主治醫師副簽。簽名必須簽
中文全名，不可只簽姓氏，而且要清晰可以辨識。
15. 其他注意事項：
〈1〉電腦設定的摘要項目，每項皆要列印出來，若該項沒有執行時，應打"Nil" 或"No" ，不可空
白。
〈2〉列印出來的摘要內容長度以2 到3 張為宜。
〈3〉列印表機的色帶不可過淡，以免影響日後影印、縮影，若顏色太淡，病歷審核人員可要求重
新製作。
〈4〉整體病歷摘要英文書寫務必流暢、簡明，且拼字清晰正確。
27
〈5〉摘要繕打完成，主治醫師須確實審核，若摘要有許多錯誤，可要求再
由住院醫師於再修正，
最後由住院醫師及主治醫師簽章才算完成。
28
參、病歷書寫實例
一、入院紀錄
二、出院病歷
三、手術紀錄
〈一〉外科實例
〈二〉婦產科實例
〈三〉骨科實例
〈四〉泌尿科實例
〈五〉耳鼻喉實例
29
Admission Note（內科）
病歷號碼:00000000
衛生福利部豐原醫院姓名:潘○○
住院序號:00000000000 床號:
出生日期:0000000 性別:男
-------------------------------------------------------------------------------------
§ 日期︰000/00/00 § 時間︰00:00 § 醫師︰ooo
-------------------------------------------------------------------------------------
 基本資料：
Name (姓名)：潘○○
Age / Sex (年齡/性別)：062 歲 /男
Occupation(職業)：商
Marital status(婚姻狀況)：已婚
Ethnic origin(族群)：Taiwanese
Place of residence(住處)：豐原區安康路 100 號
Relational past History(相關既往病史)：as mentioned below
 主訴：Shortness of breath since last night
 病史：
The patient is a 62-year-old male with the past history of (1)Old CVA of SAH and
ICH within long-term bed-ridden status and seizure sequelae (2)s/p tracheostomy
(3)Hypertension. The above diseases were regularly followed up in our CM OPD. He was
relatively stable until this Monday.
The present illness could be traced back to 4 days ago when fever was noted by
the home-care nurse. Thus, he was brought to our FAM OPD for assistance. Pneumonia
was impressed at that time and Curam was prescribed. The fever subsided after that.
However, shortness of breath occurred last night. Besides, much sticky sputum
accumulation was also noted. Due to the persistence of the above symptoms, he was
then brought to our ER.
In our ER, the physical examination revealed coarse breathing sound and fever.
The phlebotomy report showed leucocytosis with N-Seg. predominant. The CXR disclosed
ground glass opacity over both lower lungs. Under the impression of BLL pneumonia
with respiratory failure s/p Tr. + MV, he was then arranged to admit to our ICU for
further evaluation and treatment.
 既往病史：
1.DM (-), HTN (+), COPD (-), Asthma (-), TB (-), CV disease (-), CVA (-)
2.Other major systemic disease：denied
3.Surgical history：chronic respiratory failure s/p tracheostomy on 00/00/00
 社會史
1.Alcohol consumption：denied
2.Smoking：1PPD for 50 years and has quit for 4 years
3.Betel nut chewing：denied
 過敏史：
1. Denied drugs or food allergy history
 家族史：
30
UTI
HCC. Sepsis
HCC. p’t Gastric Traffic

ca. Accident
 系統環顧：
1. Systemic：fever (-), BW loss (-), easily-fatigue (-), change of appetite (-),
dizziness(-)
2. Skin：petechiae (-), purpura (-), skin rash (-), itching (-)
3. HEENT：blurred vision (-), strabismus (-), ocular pain (-), ear ache (-), otorrhea
(-), hearing loss (-), tinnitus (-), vertigo (-), nasal stuffiness (-), nasal
discharge (-), nasal bleeding (-), gum bleeding (-), glossitis (-), sorethroat (-)
4. Cardiovascular：exertional chest tightness (-), PND (-), orthopnea (-), syncope
(-), palpitation (-), intermittent claudication (-)
5. Respiratory：dyspnea (+), cough (+), chest pain (+), hemoptysis (-)
6. GI：anorexia (-), nausea (-), vomiting (-), dysphagia (-), heart burn (-), acid
regurgitation (-), abdominal fullness (-), hunger pain (-), midnight pain (-),
constipation (-), diarrhea (-), melena (-), change of bowel habit (-), small
caliber of stool (-), tenesmus (-), flatulence (-)
7. Urogenital：flank pain (-), hematuria (-), urinary frequency (-), urgency (-),
dysuria (-), hesitancy (-), small stream of urine (-), impotence (-), nocturia
(-), polyuria (-), oligouria (-)
8. Musculoskeletal：bone pain (-), arthragia (-), muscle ache (-), weakness (-)
9. Metabolic：heat intolerance (-), cold intolerance (-), thirsty (-)
10. Nervous：numbness (-), paresis/plegia (-)
 理學檢查：
General appearance：a well-developed male with acute ill-looking, no respiratory
distress
Consciousness：clear/drowsiness/stupor/coma, GCS-E4V5M6, JOMAC-intact/disorientation
Vital signs：BP-135/80 mmHg, BT-36.2°C, PR-95/min, RR-18/min
Integument：normal skin turgor, edema (-), eruption (-), pethechia (-), ecchymosis
(-), clubbing finger (-), cyanotic nail (-), desquamation (-)
HEENT：Head-normal skull configuration and hair distribution, exophthalmos (-),
ptosis (-)
Eyes-Conjuctiva-pale (-), sclera-icteric (-), EOM-intact, normal visual
acuity and color perception, Pupils-isocoric (+) 3mm/3mm, light reflex-
R/L: (+/+)
Ears-discharge from ears (-), hearing impairment (-)
Nose-normal shape, deviation of septum (-), polyps (-), patent of airway,
tenderness of sinus (-), congestion (-), rhinorrea (-), post-nasal
dripping (-)
Mouth-cyanotic lips (-), cold sores (-), oral ulceration (-), tongue
deviation (-), swelling or erythematus change tonsils (-)
31
Throat-injected (-), gum bleeding (-)
Neck：supple (+), LAP (-), JVE (-), goiter (-), palpable mass (-)
Chest：
(1) Inspection-normal contour of ribs cage with symmetric expansion, kyphosis (-),
scoliosis (-)
(2) Palpation-normal tactile fremitus, subcutaneous emphysema (-)
(3) Percussion-resonance, abnormal dullness (-)
(4) Auscultation-wheezing (-), rhonchi (+) over right upper lung field, crackle (-),
stridor (-)
Heart：
(1) Inspection-no visible PMI
(2) Palpation-thrill (-), heave (-)
(3) Percussion-normal shape
(4) Auscultation-RHB, no murmur.
Abdomen：
(1) Inspection-flat shape, superficial vein engorgement (-), OP scar (-)
(2) Auscultation-Normal active bowel sound, gastric succussion (-), bruits (-)
(3) Palpation-soft, tenderness(-), rebounding tenderness(-), liver and spleen not
palpable, mass palpable(-)
(4) Percussion-normal liver and spleen span, shifting dullness (-)
Back and spine：normal curvature, tenderness (-), root pain (-), knocking pain (-)
Anus and rectum：no rectal mass
Extremities and joints：freely moveable, pitting edema (-), clubbing finger (-),
tremor (-), petechia (-), purpura (-), cyanosis (-)
Peripheral pulsation：
CA BA RA FA PA DPA PTA
RIGHT +++ +++ +++ +++ ++ ++ ++
LEFT +++ +++ +++ +++ ++ ++ ++
Nervous system：Mentality-well orientation, registration, attention and calculation

Cranial nerves-intact
Motor-MP upper 5/5, lower 5/5
DTR BJ ++/++, TJ ++/++, KJ ++/++
Babinski sign -/-, rigidity (-), spasticity (-)
Sensory-symmetric pinprick, ligh touch, and joint position
Coordination-F-T-N OK, H-T-S OK, RAM OK
Tendem walking and Romberg test OK
 實驗室數據：
1. CBC (Date 00/00/00)
WBC 6.4 K/UL (Segment/Lymphocyte 70/16), Hb 12.4 g/dl, MCV 96.8fl, HCT 37%,
PLT 229K/UL, PT 12.6 sec, INR 1.29, APTT 28.1/ 26
2. SMA (Date 00/00/00)
GPT: 28 IU/L, BUN/Cr: 19.4/1.6 mg/dl, LDH: 426IU/L, Na/K: 141/3.3 mmol/l
Glucose PC: 104mg/dl
3. ECG-sinus tachycardia
4. Urinalysis (Date 00/00/00)
Sugar -, Ketone body -, Sp. Gr 1.013, OB ++, PH 7.0, protein -, Urobilinogen -,
Nitrite -, WBC 0-1 HPF, RBC 20-25 HPF, Epithelial cell 0-1 HPF, Bacteria -
5. CXR-
32
 入院診斷：
1.BLL pneumonia with respiratory failure s/p Tr. + MV
2.Old CVA of SAH & ICH within bed-ridden status and seizure sequelae
 主要計劃：
1.Laboratory studies include a chest radiography including CXR and chest CT scan,
tests of
hemostasis (PT and APTT), CBC to look for anemia and thrombocytopenia.
2.Liver function tests to evaluate for hepatic dysfunction if the platelet count is
low or the INR is
prolonged.
3.Sputum bacterial and mycobacterial stains and cultures, sputum cytology
4.Urinalysis to evaluate for RBCs or RBC casts that may be associated with
Wegener’s
granulomatosis or Goodpasture’s syndrome.
5.Arrange bronchoscopy to localized the specific site and identify the cause of the
bleeding. Collect
bronchoalveolar lavage fluid for cytology and culture (mycobacterial, fungal and
bacterial).
6.Consider arrange chest echogram and echo-guided aspiration if the lesion could be
approach by
chest echgram or poorly response to antibiotics treatment.
7.Supportive care, bed rest, mild cough suppression and avoidance of excessive
thoracic manipulation
8.Pulse oximetry monitoring and supplement oxygen if desaturation was noted.
9.If massive hemoptysis happened, let patient be positioned with bleeding side in a
dependent position to reduce aspiration of blood into contralateral lung.
10.Consider arrange embolization or urgent surgical intervention if active massive
hemoptysis was Noted.
 精神層面：
1. 家庭支持力強。
2. 女兒是本院護理人員。
3. 病患對自身病情尚不甚清楚。
主治醫院蓋章：○○○ 住院醫師蓋章：○○○
Admission Note （外科）

病歷號碼:00000000
衛生福利部豐原醫院姓名: ○○○
住院序號:00000000000 床號:1700-00
出生日期:00/00/00 性別:女
------------------------------------------------------------------------------------
§日期︰101/00/00 § 時間︰00︰00 § 醫師︰○○○
------------------------------------------------------------------------------------
33
■ 基本資料
Name (姓名)：○○○○
Age / Sex (年齡/性別)：00 歲 /女
Occupation(職業)：無
Place of residence(住處)：○○○○○○○○○○○○
■ 主訴
Intermittent abdomen pain for 3 months
■ 現況病史
This 00 y/o woman is a case of hypertension and arrhythmia with Af , and she
was regular follow up at LMD more than 20+ years.
According to the statement of the patient and her family, she suffered from
intermittent epigastric pain for 3 months. There was denied body weight
loss,fever, diarrhea or vomiting. In this March, she visited 協和
hospital and endoscopy was suggested but she was refused. However, anorexia and
easy abdomen distension were developed in recent weeks. So endoscopy was
arranged today, which revealed diffuse ulcerative masses lesion extending whole
antrum and anaularis to low body and biopsy was done. Under the impression of
Borrmann type III advanced gastric cancer,antrum, angularis and low body s/p
biopsy, she was transferred to our hospital form 協和 hospital and admission
for
further evaluation and treatment.
■ 既往病史
1. Diabetes mellitus: denied
2. Hypertension & Af with regular follow up at LMD for 20+ years
3. Other systemic disease: as mentioned above
4. Surgical history: s/p cataract
5. Past psychiatric history(過去精神病史): denied
■ 社會史
1. No habit of alcoholic drinking
2. No smoking
3. No habit of betel nut chewing
4. Travel history: no recent travel history
5. Occupation: nil
6. Contact history(接觸史): not significant
7. Cluster history(群聚史): not significant
■ 過敏史
No known alleric history to drug, contrast medium, blood transfusion, food or
environmental substance
■ 家族史
No significant related family history
■ 系統環顧
1.General: no fever, body weight loss, easy-fatigue, change of appetite
2.Skin: no petechiae, purpura, skin rash, itching
34
3.HEENT: no blurred vision, strabismus, ocular pain, earache,
otorrhea, hearing
loss, tinnitus, vertigo, nasal stuffiness, nasal discharge, nasal bleeding,
gum bleeding, sorethroat
4.Cardiovascular: no exertional chest tightness, orthopnea, syncope, palpitation
intermittent claudication
5.Respiratory: no dyspnea, cough, chest pain, hemoptysis
6.GI: no anorexia, nausea, vomiting, dysphagia, heart burn, acid regurgitation,
abdominal fullness, hunger pain, constipation, diarrhea, melena, change of
bowel habit, tenesmus
7.Urogenital: no flank pain, hematuria, urinary frequency, urgency, dysuria,
hesitance, nocturia, polyuria, oliguria.
8.Musculoskeletal: no arthralgia, muscle ache, weakness.
9.Metabolic: no heat or cold intolerance, easy thirsty
10.Nervous: no numbness, paresis, paralysis neurological sign
■ 理學檢查
【The Major Findings of Physical Examination On Admission 】
●Consciousness：alert
●Coma Scale：E(4)M(6)V(5)
●General appearance: female patient with chronic ill, no cardiopulmonary
distress
●Vital Signs：BP=145/83mmHg, PR=105/min, RR=18/min, BT=36.2℃
●HEENT：
◇Head：no open wound, no scalp hematoma, no hair loss, no scar, no tenderness,
no
cold sweating,
◇Eye：no abnormal deviation of eye-ball, no exophthalmos. no ptosis,
Pupil：isocoric. Size＆Light Reflex：L3mm(+)/R3mm(+)
Conjunctiva：pink, not pale,(no anemic change).
Sclera：not icteric, no petechiae, no hemorrhage, no ulcer/Scar.
◇Ear：intact and clear auditory cannel, no discharge.
◇Nose：No epistaxis, no rhinorrhea, no polyp, no deformity of nasal septum.
◇Neck：supple, no stiffness, no motion-limited, no jugular vein engorgement.
No lymph node adenopathy, No palpable mass, No open wound/Tenderness.
No using of acceaaory-aspiratory muscles. No Central Venous Catheter noted.
●Chest：
no using of accessory-respiratory muscle,
symmetric expansion, intermittent shortness of breathing,
︵ no subcutaneous emphysema, no open wound of chest wall.
∕ ﹨
｛`︷'｝Heart sound：Irregular heart beat with Gr-II systolic murmur.
╰─╯ Breathing sound：Bilateral coarse breathing sound.
╴ ∕ ﹨＿ ●Abdomen：
∕ ＼〒／ ﹨ Soft, not guarded. Scaphoid in appearance.
﹨ ∕ Hypo-active bowel sound
﹨ ⊙ ⊙∕ Liver/Spleen: non-palpable,
）︾ˇ︾（ Tenderness：over A2 area
∕ ﹨ Rebunding pain：(-)
∕ x ﹨ Palpable mass：(-)
35
▏ ｜
▏ ∕︶﹨ ｜
●Back：Knocking pain:(-) Radiation pain:(-), No compression sore wound.
●Extremities：Full range of motion, no deformity
■ 實驗室數據
** 尿液檢查 **
Date(Time) PH 比重檢查蛋白質定性糖定性檢查尿膽素原檢
1010504(1329) 7.000 1.004 - - 0.100
膽紅素苯酮體檢查亞硝酸鹽檢 OB RBC
- - - - 0-2
WBC Epithelial Bacteria WBC(定性)
0-5 0-5 - -
--------------------------------------------------------------------------------
** 血液學檢查 **
Date(Time) W.B.C 白血 Hemoglobin Platelet c N-Seg Lymph
1010504(1329) 5.500 12.500 229.000 66.400 23.000
Baso Eosin MONO
0.300 1.400 8.900
** 一般生化學檢查 **
Date(Time) BUN(Blood) Glucose(AC Ca(Blood) Creatinine Na 鈉(boold
1010504(1329) 13.000 129.000 9.300 0.800 141.000
K 鉀(Blood) S-GOT(AST) S-GPT(ALT) Alkalinpho 乳酸脫氫脢
4.300 29.000 14.000 101.000 155.000
白蛋白 Alb e-GFR 腎絲 STAGE
3.400 69 STAGE 2
--------------------------------------------------------------------------------
■ 入院診斷
1. Borrmann type III advanced gastric cancer.
2. Gastric ulcers
3. Hypertensive cardiovascular disease
4. Af
5. Ileus with stool impaction
■ 主要計畫
1. Admission routine study
2. NPO & PPI iv form used
3. Arrange abdomen sonography and abdomen CT scan
4. Consult CV for pre-operation evaluation
5. Consult GS for evaluation with surgical condition
6. Give laxative agent used.
■ 精神層面
心理社會評估
1.情緒狀況:
□平靜 ▇焦慮 □憂鬱 □淡默 □激動 □無法評估
2.知情程度:
▇本人了解病情 □本人不知病情
36
3.主要照顧者:
□無 ▇配偶 □父母 □子女 □兄弟姊妹 □祖父母
□外傭 □安養中心 □朋友 □同居人 □其他________
4.主要決策者:
▇本人 □配偶 □父母 □子女 □兄弟姊妹 □祖父母
□朋友 □同居人 □其他________
5.宗教信仰:
□無 ▇傳統信仰 □佛教 □基督教 □天主教 □回教 □其他________
醫師簽章：○○○
Admission note (小兒科)

病歷號碼:00000000
衛生福利部豐原醫院姓名:鄭 00
住院序號:00000000000 床號:1508-02
------------------------------------------------------------------------
-----------------------------------------------------
§日期︰000/00/00 § 時間︰00:00 § 醫師︰ooo
------------------------------------------------------------------------
-----------------------------------------------------
■ 基本資料
Name (姓名)：鄭 OO
Age / Sex (年齡/性別)：08 個月/男
Marital status(婚姻狀況)：未滿 15 歲者
Ethnic origin(族群)：.台灣
Place of residence(住處)：台中市東勢區
Relational past History(相關既往病史)：
1. No systemic disease history
■主訴
37
fever for 3 days
■現況病史
This 8m/o boy with past history of acute bronchitis was admitted via
OPD due to fever
off and on and productive cough with red eyes for 3 days.
He was suffered from fever since 3 days ago,cough with sputum,rhinorrhea
were also noted.
Although he was treated at LMD but still in vain,fever/productive
cough,red eyes were still
noted. So he was sent to our OPD for help. The labotory data
show:influenza A weak postive.And then
he was admitted to our ward for further evaluation and management .
Throughout the whole course, there were fever,cough,rhinorrhea,diarrhea,
and abdominla pain;
there were no cyanosis, short of breath,vomit, frequency, urgency, limbs
weakness, or skin rash
noted.
■ 既往病史
Past hitory:
(1)Birth history: Full term
(2)Vaccination: as schedule
(3)Newborn screen: normal
(4)Growth and development: as milestones
(5)Previous hospitalization or Operation history:denied
(6)Chronic illness: denied
(7)Development survey :
First smile （1.5~3 m/o）： normal
Head control （3 m/o）： normal
Roll over （4~6 m/o）： normal
Transfer object （5~7 m/o）： normal
Sit alone （7 m/o）： normal
Crawl （8 m/o）： normal
Stand with support （9 m/o）： normal
Stand alone （11 m/o）： normal
Walk alone （12 m/o）： normal
Words （12 m/o）： normal
Sentences （19 m/o）： normal
Scribble （12~18 m/o）： normal
Run （18~24 m/o）： normal
Ride tricycle （2~3 y/o）： normal
Dress （4~5y/o）： normal
Travel history : **denied
Contact history: HIS MOTHER HAD FEVER
38
Cluster history: **denied
■社會史
主要照顧者:父母親
日間照護:home
家中飼養寵物:無
毒物暴露:無
■過敏史
※依藥理分類 denied
※依處置代碼 denied
※特殊記錄 denied
■家族史
No hereditary disease or similar disease among close family members
■系統環顧
Review of system
General: **fever,no weakness
HEENT:no dizziness,no nausea,no headache,** injected conjunctiva,
no otolgia,** nasal stuffness,** rhinorrhea,** sorethroat
Respiratory:** cough,no sputum,no chest tightness
Cardiovascular:no palpitation,no cyanosis
GI:no abdominal pain,no vomitting,no diarrhea,no constipation
GU:no frequency,no urgency,no dysuria
Neurologic:no vertigo,no seizure
Muscle-skeletal:no abvious abnormality ,no limbs weakness
Skin:no defect,no rash
■理學檢查
BW: 9.5kg
Vital sign: BT: 39.4℃
General appearance: Conscious: clear acutely ill , activity decrease
oxygenation and perfusion:pink and warm
capillary refilling time< 2sec
HEENT: Dry lip and mucosa
No craniofacial dysmorphism
Conjuntiva :injectied ;Sclera:not icteric
Ear drums: not injected
Nose:no deformity
Throat:injected Tonsils: no injected
Neck:supple ,no LAP
Chest:
Breathing sound :coarse , no Wheezing, no Rales ,** Rhonchi
Symmetric expansion
Retraction sign:no subcostal retraction , no suprasternal
39
retraction
Heart:
Regular heart beat, no Murmur ,no Tachycardia
Abdomen:
Soft and flat , Bowel sound:normoactive , tympanic
no tenderness over periumbilical ,no Rebounding pain
Liver/Spleen :impalpable , no muscle guarding
Extremities:
Freely movable ,no pitting edema ,no acracyanosis
SKIN:
Tugor:decrease,no rash ,no vesicles
Neurological examination : Cranial nerves: no focal sign
MP + 5 all DTR 2+ all
no Brudzinski sign, no Kernig sign
ＤＴＲＭＰ
++ ｜ ○ ｜ ++ 5｜ ○ ｜5
└─｜─┘ 　　 └─｜─┘
┌｜┐　　　　 ┌｜┐
++　｜｜ ++ 5 ｜｜ 5
■實驗室數據
** 尿液檢查 **
1010330(1417) 6.500 1.003 - - 0.100
- - - - 0-2
0-5 0-5 - -
------------------------------------------------------------------------
Date(Time) R.B.C 紅血 W.B.C 白血 Hemoglobin Hematocrit Platelet c
1010330(1417) 4.730 9.700 9.900 30.400 330.000
MCH MCHC MCV N-Seg Lymph
20.900 32.500 64.300 46.100 40.900
Baso Eosin MONO RDW PDW
0.700 0.400 11.900 17.700 17.200
MPV
8.900
------------------------------------------------------------------------
Date(Time) C.R.P-Neph
1010330(1417) 0.800
** 病毒學檢查 **
Date(Time) Infl A Ag Infl B Ag
1010330(1417) Weak Negative
40
■ 入院診斷
780.6 發燒
485 支氣管性肺炎
372.00 急性結膜炎
■ 主要計劃
1.on pediatric ward/sbr routine
2.iv fluid and supportive care
3.septic workup b/c
4.empiric antibiotic with ampolin
5.note fever pattern and vital sign
6.special consultation if needed
7.family education and discussion of disease course and management
plans
■精神層面
情緒易怒:否
睡眠障礙:否
溝通學習障礙:否
過動傾向:否
尿床:否
異食習慣:否
41
Admission Note（婦產科）
病歷號碼:00000000
衛生福利部豐原醫院姓名:洪 00
住院序號:00000000000 床號:1306-02
出生日期:0000000 性別:女
-------------------------------------------------------------------------------------
--
§ 日期︰000/00/00 § 時間︰00:00 § 醫師︰○○○
-------------------------------------------------------------------------------------
--
■基本資料
Name (姓名)：洪 00
Occupation(職業)：服務業
Marital status(婚姻狀況)：married
Ethnic origin(族群)：Taiwanese
Place of residence(住處)：台中市豐原區 00 路 000 巷 00 弄 00 號 0 樓之 3
1. No systemic disease history
■主訴
Positive finding(CIN3) of annual examination of Pap smear in this March
■現況病史
This 49 years old woman without systemic disease history was admitted via
OPD
due to positive finding(CIN3) of annual examination of Pap smear in this March.
She was previously healthy until this March, when annual examination of Pap
smear revealed CIN3. There was no other discomfort or symptoms noted. Thus she
visited our OPD, where Pap smear and colposcopic punctaion biopsy was done. Both
pathologic study showed cervical intraepithelial neoplasia grade 3. Hysterectomy
was suggested. Thus she was admitted for surgical intervention.
■既往病史
Past History :
1.DM: denied
2.Hypertension: denied
3.Denied other systemic disease
4.Surgical history:denied
■Menstrual History:
Menarche at 14 Yrs.
Regularity: Yes
Character & Amount: Moderate amount
Dysmenorrhea:no
Blood clots:no
42
■社會史
2. No Smoking
4. Travel history : no recent travel history
5. Occupation : 服務業
6. Contact history(接觸史)：not significant
7. Cluster history(群聚史)：not significant
■過敏史
※依藥理分類: NKA
※依處置代碼: NKA
※特殊記錄: NKA
■家族史
■系統回顧
1.General: No fever, No loss of body-weight, No easy-fatigibility,
No change of appetite, No dizziness
2.Integument: No petechiae, No skin rash, No itching.
3.HEENT:
No blurred vision, No strabismus, No ocular pain, No ear ache,
No otorrhea, No hearing loss, No tinnitus, No vertigo,
No nasal bleeding,
No gum bleeding, No glossitis, No sorethroat.
4.Respiratory: No dyspnea, No cough, No chest pain, No hemoptysis.
5.Cardiovascular:
No exertional chest tightness, No Paroxysmal nocturnal dyspnea(PND)
No orthopnea, No syncope, No palpitation, No intermittent claudication.
6.GI:
No anorexia, No vomiting, No dysphagia, No heart burn,
No acid regurgitation, No abdominal fullness, No hunger pain, No midnight pain
No onstipation, No diarrhea, No melena, No change of bowel habit,
No small caliberofstool, No tenesmus, No flatulence.
7.Genitourinary:
No flank pain, No hematuria, No urinary frequency, No urgency,
No dysuria, No nocturia, No polyuria, No oliguria.

No intramenstrual disorder
生育史：G3P3A0, Last menstrual period(LMP): 101/04/20
8.Metabolic and endocrine: No heat-intolerance, No cold-intolerance, No thirsty
9.Hematologic: No purpura,
10.Nervous: No numbness, No paresis,
11.Musculoskeletal: No bone pain, No arthralgia, No muscleache, No weakness
■理學檢查
●General Appearance: Moderate nourished and developed.
Fair looking
●Integument: normal skin turgor, no edema, no eruption/rash, no petechia
43
●Mental state: Coma Scale：E(4)M(6)V(5)
●Consciousness：clear
●Vital Signs：BP= 143/85 mmHg, PR= 78/min, RR= 20/min, BT= 37.4℃
●HEENT：
◆Head：No obvious wound or skin errosion, no Scalp hematoma, no scar,
no tenderness, normal skull configuration and hair distribution without
deformity.
◆Eyes：no exophthalmos, no ptosis, full EOM, no nystagmus, no abnormal
deviation of eye-ball, no diplopia, normal visual acuity and color
perception
conjunctiva：pink, not pale, not anemic.
Pupils：isocoric. Size＆Light Reflex：L3.0mm(+)/R3.0mm(+)
◆Ear：Intact eardrum, intact and clear auditory cannel,
no discharge from ears, no hearing impairment.
◆Nose：No rhinorrhea, No epistaxis, no polyp, no deformity of nasal septum.
◆Neck：
supple, not stiff, with fair range of motion,
no jugular vein engorgement, no carotid bruit, thyroid gland not enla
no lymph node adenopathy, no palpable mass. No open wound/Tenderness.
◆Tonque: midline, no ulcer, no deformity,
◆Mouth: no oral ulcer,
◆Throat：normal palatal movement, tonsils not injected,
no congestion of posterior throat wall.
●Chest：
◆Inspection: normal contour of ribs cage with bilateral-side obvious expansion
◆Palpation: normal tactile fremitus, no subcutaneous emphysema
◆Percussion: resonance; no abnormal dullness.
◆Auscultation: clear Breathing sound, bilateral.
●Heart:
◆Inspection: no visible PMI
◆Palpation: no thrill, no heave
◆Percussion: normal shape
◆Auscultation: regular heart beat, no murmur
●Abdomen:
╰─╯ ◆Inspection: flat shape,
╴ ∕Ｖ﹨＿ No op scar, no superficial vein engorgement
∕ ＼／ ﹨ ◆Auscultation: Normal-active bowel sound,
﹨ no gastric succussion splash, no bruits.
﹨ ⊙ ⊙∕ ◆Palpation: soft,
）︾ˇ︾（ No tenderness
∕ ﹨ No rebunding tenderness
∕ x ﹨ Liver/Spleen: non-palpable
▏ ___ ▏ No palpable mass
◆Percussion: normal liver and spleen span,
no shifting dullness, no constovertebral angle knocking pain.
●Back&spine：normal curvature, no open wound, no scar,
no tenderness, no root pain, no flank knocking pain, no Radiation
pain.
●Extremities&Joints：freely Movable, not limited on full range.
44
no pitting edema, no swelling, no
tenderness,
no Deformity, no clubbing finger, no cyanotic nail.
●Peripheral pulsation:
頸動脈肱動脈橈動脈股動脈足背動脈脛後動脈
RIGHT ++ ++ ++ ++ ++ ++
LEFT ++ ++ ++ ++ ++ ++
●Nervous system:
◆Mentality: fair orientation, registration, attention and calculation.
◆Cranial nerves: intact
◆Motor --MP: upper5/5 lower 5/5
◆DTR : BJ++/+ TJ++/++ KJ++/++
◆Babinski sign-/- No rigidity or spasticity
◆Sensory: symmetric pinprick ,light touch ,and joint postion
◆Coordination: fair F-T-N ,fair H-T-S ,fair RAM
Fair Tendem walking and Romberg test
●Genital organ: intact, no herniation,
●Anus&Rectum: intact, no hemorrhoid, no rectal mass
實驗室數據
Date(Time) PT(INR) PT(sec") APTT
1010504(1045) 1.010 10.300 26.000

1010504(1045) 4.060 6.400 13.000 37.500 215.000
MCH MCHC MCV RDW PDW
32.000 34.800 92.100 12.600 15.900
MPV
8.300
--------------------------------------------------------------------------------
Date(Time) BUN(Blood) Glucose(AC Creatinine Na 鈉(boold K 鉀(Blood)
1010504(1045) 13.000 120.000 0.800 141.000 3.800
Cl(Blood) S-GOT(AST) S-GPT(ALT) e-GFR 腎絲 STAGE
105.000 20.000 20.000 76 STAGE 2
** 輸血前檢查 **
Date(Time) A.B.AB.O b RH(D)型檢
1010504(1045) O Positive
■ 入院診斷
1. Cervical intraepithelial neoplasia grade 3
■ 主要計劃
1. Arrange hysterectomy today
2. Post-op care and management
3. Symptomatic treatment
45
■ 精神層面
Attitude : Cooperative, no defensive nor nervous
Attention & Concentration : Fair
Mood : Euthymic, no dysphoric, irritable, depressive, agitation nor fear
Affect : Appropriate, No anger, sad, nor anxious
Speech : Coherent, relevent and spontaneous
Behavior: No aggressive, violent nor suicidal attempt
Thought : No delusion
Perception : No hallucination
Admission Note（骨科）
病歷號碼:00000000
衛生福利部豐原醫院姓名:000
住院序號:00000000000 床號:16○○-02
出生日期:0000000 性別: 男
---------------------------------------------------------------------------------------
§ 日期︰000/00/00 § 時間︰00:00 § 醫師︰ooo
--------------------------------------------------------------------------------------
■基本資料
Name (姓名)：王 O○
Place of residence(住處)：○○市○○里○○路○○號
■主訴
left knee pain for years
■現況病史
The 86 y/o male patient was a case of diabete mellitus with insulin control. He
sustained left knee pain with walking limitation for several years. The joint pain of
knee is often a deep ache localized to the medial site. Typically, it is aggravated by
joint use and relieved by rest .At first, he did not pay attention until as the disease
progresses, it may become persistent. Nocturnal pain, interfering with sleep,.
Stiffness of the involved joint after a period of inactivity may be prominent .The knee
46
pain became worse and worse with progressive limping gait, poor
excercise tolerance, poor stairs climbing,and easy fatigue on left
knee in later . Although he ever visited LMD for help ,where conservative treatment and
drug was given, but in vain. So he came to our OPD for help for several weeks ago ,
where physcial exmination of the knee joint revealed localized tenderness and soft
tissue swelling. Bony crepitus was characteristic. Synovial effusions were also found.
Palpation revealed some warmth over the joint. Periarticular muscle atrophy were seen
glossly may be due to disuse or reflex inhibition of muscle contraction. There were
gross deformity, bony hypertrophy, subluxation, and marked loss of joint motion knee
swelling with varus deformity and x-ray of knee was revealed OA change of left
knee.After the doctor's advice, he is admitted to our ward for TKA
■既往病史
1. Diabete Mellitus type II with insulin control for 5 years
2. hypertension： denied
3. OP histroy: right septic knee s/p debridment 2 years
4. Denied other systemic disease
■社會史
2. No Smoking
■過敏史
No food allergy
Drug allergy: denied
No alcohol consumption and smoking history
No Betal nut use history
■家族史
■系統回顧
1.General:No fever, No loss of body-weight, No easy-fatigibility,
3.HEENT:No blurred vision, No strabismus, No ocular pain, No ear ache,
No nasal stuffiness, No nasal discharge, No nasal bleeding,
4.Respiratory :No dyspnea, No cough, No chest pain, No hemoptysis.
5.Cardiovascular:
No exertional chest tightness, No Paroxysmal nocturnal dyspnea(PND),
6.GI:No anorexia, No nausea, No vomiting, No dysphagia, No heart burn,
47
No onstipation, No diarrhea, No melena, No change of bowel
habit,
7.Genitourinary: No flank pain, No hematuria urinary frequency, No urgency
dysuria, No hesitancy, No small stream of urine, No impotence, No nocturia,
No polyuria, No oliguria.
10.Nervous :No numbness, No paresis,
11.Musculoskeletal:**right knee bone pain,arthralgia,muscleache, weakness
■理學檢查
General Appearance: Moderate nourished and developed.
Fair looking
Integument: normal skin turgor, no edema, no eruption/rash, no petechia
Mental state: Coma Scale：E(4)M(6)V(5)
Consciousness：clear
Vital Signs：BP= 143/85 mmHg, PR= 78/min, RR= 20/min, BT= 37.4℃
HEENT：
no tenderness, normal skull configuration and hair distribution without
deformity.
◆Eyes：no exophthalmos, no ptosis, full EOM, no nystagmus, no abnormal
deviation of eye-ball, no diplopia, normal visual acuity and color
perception
conjunctiva：pink, not pale, not anemic.
◆Ear：Intact eardrum, intact and clear auditory cannel,
no discharge from ears, no hearing impairment.
◆Neck：
supple, not stiff, with fair range of motion,
◆Tonque: midline, no ulcer, no deformity,
◆Mouth: no oral ulcer,
◆Throat：normal palatal movement, tonsils not injected,
no congestion of posterior throat wall.
Chest：
◆Inspection: normal contour of ribs cage with bilateral-side obvious expansion
◆Palpation: normal tactile fremitus, no subcutaneous emphysema
◆Percussion: resonance; no abnormal dullness.
◆Auscultation: clear Breathing sound, bilateral.
Heart:
◆Percussion: normal shape
48
Abdomen:
╰─╯ ◆Inspection: flat shape,
╴ ∕Ｖ﹨＿ No op scar, no superficial vein engorgement
∕ ＼／ ﹨ ◆Auscultation: Normal-active bowel sound,
﹨ ⊙ ⊙∕ ◆Palpation: soft,
）︾ˇ︾（ No tenderness
∕ ﹨ No rebunding tenderness
∕ x ﹨ Liver/Spleen: non-palpable
▏ ___ ▏ No palpable mass

Back&spine：normal curvature, no open wound, no scar,

no tenderness, no root pain, no flank knocking pain, no Radiation
pain.
Extremities and joints
Gait: antagia gait.
No muscular atrophy in bilateral lower limbs
Varus deform on right knee noted
No neurologic deficient
Right Left
ROM 15-90 5-120
Alignment Varus Neutral
Mechanical axis 18 degree varus 2degree varus

Anatomical axis 12 degree varus 5degree valgus
Ligament laxityM/L +/- -/ -
Peripheral pulsation:
頸動脈肱動脈橈動脈股動脈足背動脈脛後動脈
RIGHT ++ ++ ++ ++ ++ ++
LEFT ++ ++ ++ ++ ++ ++
Nervous system:
◆Mentality: fair orientation, registration, attention and calculation.
◆Cranial nerves: intact

◆Motor --MP: upper5/5 lower 5/5
◆DTR : BJ++/+ TJ++/++ KJ++/++
◆Babinski sign-/- No rigidity or spasticity
◆Coordination: fair F-T-N ,fair H-T-S ,fair RAM
Fair Tendem walking and Romberg test
Genital organ: intact, no herniation,
Anus&Rectum: intact, no hemorrhoid, no rectal mass
實驗室數據
49
1.010 10.300 26.000
4.060 6.400 13.000 37.500 215.000
32.000 34.800 92.100 12.600 15.900
MPV
8.300
13.000 120.000 0.800 141.000 3.800
105.000 20.000 20.000 76 STAGE 2
O Positive
■ 臨床臆斷:(Impression)
1. left knee advanced OA
2. diabetes mellitus
主要計劃:
Total Knee Arthroplasty, left
Operation indication:
1. left knee pain with disability
2. medical treatment failed
3. X-ray showed advanced OA change
■ 精神層面
Anxiety to the progression of rehabilitation
Well family support
Well rehabilitation motivation
50
Admission Note（復健科）
病歷號碼:00000000
衛生福利部豐原醫院姓名:陳 00
住院序號:00000000000 床號:3**8-02
出生日期:0000000 性別:女
-------------------------------------------------------------------------------------------
§ 日期︰000/00/00 § 時間︰00:00 § 醫師︰ooo
------------------------------------------------------------------------------------------
■基本資料
Name (姓名)：陳 oo
Ethnic origin(族群)：台灣
Place of residence(住處)：魚池鄉東池村福興巷 5-2 號
■主訴
Admission for rehabilitation due to four limbs weakness since 100/12/25
■現況病史
This 80 year-old female with type 2 diabetes mellitus was admitted via ER due to the
reason as above. She had suffered from headache, dizziness and nausea for 3 days. She also
complained of chillness and chest tightness, but she denied fever. While visiting our
ER(100/12/25), physical examination showed clear consciousness with GCS: E4V5M6 and ptosis
of right eye. Lab data disclosed slight leukocytosis and impaired renal function. Brain CT
revealed diffuse SAH and left IVH, suspect aneurysm ruptured.Therefore she was admitted to
our NSICU for further care and management.100/12/27 consciouness loss followed up brain MRI
showed : posterior communicating artery aneurysm and s/p craniotomy aneurysm clipping c/w
EVD insertion,Brain CT: Hydrocephalus,s/p intracerbral endoscopy revision EVD on
101/01/03,the EVD was remove on 101/01/09.However,she had type 2 DM,sugar was poor
control,RI regular control.
After admission and treatment for 17 days, difficulty weaning and ventilator dependence
due to poor underling disease, she was transferred to RCC for further respiratory care and
arrange weaning protocol on 101/01/10. On 101/01/11 try T-piece was smooth over 5 days,she
was referred to ward care，she was weaning on 1/15 then transfer to ward from RCC on
1/16.Due to respiratory distress,suggest tracheostomy was indication,family consider. On
1/17 follow up Brain CT revealed Hydrocephalus.Left porgrammable VP shunt shunt
+tracheosotmy tube was done on 01/19 and admitted to NSICU.Her clinical condition was
stable,on 01/25 transferred to ward.
On 101/04/05, she was transferred to self-paud ward for further rehabilitation under her
family's
51
ask. On 101/04/12, acute asthma attact with pneumonia was noted. Due to that, she was
admitted to our Chest ward for further treatment. After antibiotics treatment, her clinical
was improved. And then, she was transferred to 埔里榮院 under her family's decide.
Today, she was admitted to our ward due to limbs weakness and poor functional and ADL
status.
■既往病史
1. Type 2 diabetes mellitus : under mixtared controld
2. Hypertension : under medical control
3. Operation history : * On 100/01/27 Craniotomy aneurysm clipping c/w EVD
* On 100/01/03 Intracerbral endoscopy revision EVD
* On 100/01/19 Left porgrammable VP shunt shunt +
tracheosotmy tube
■社會史
2. No Smoking
■過敏史
※依藥理分類:NKA
※依處置代碼:NKA
■家族史
■系統回顧
1.General:No fever, No loss of body-weight, No easy-fatigibility,
3.HEENT:No blurred vision, No strabismus, No ocular pain, No ear ache,
No nasal stuffiness, No nasal discharge, No nasal bleeding,
4.Respiratory :No dyspnea, No cough, No chest pain, No hemoptysis.
5.Cardiovascular:
No exertional chest tightness, No Paroxysmal nocturnal dyspnea(PND),
6.GI:No anorexia, No nausea, No vomiting, No dysphagia, No heart burn,
No onstipation, No diarrhea, No melena, No change of bowel habit,
7.Genitourinary: No flank pain, No hematuria urinary frequency, No urgency
dysuria, No hesitancy, No small stream of urine, No impotence, No nocturia,
52
No polyuria, No oliguria.
10.Nervous :No numbness, No paresis,
11.Musculoskeletal:**right shoulder bone pain,arthralgia,muscleache, weakness
■理學檢查
1.General appearance: moderate developed, bilateral side weakness sitting on bed
2.Integument: normal skin turgor, no petachiae, no ecchymosis
3.HEENT: Head: no fracture, no open wound
Eye: no pale conjunctiva
no icteric sclera
no ptosis, blurred vision
Ear: no deformity, discharge
Neck: supple, no LAP, no JVE,surgical scar(+)
Throat: no throat pain, throat congestion
4.Respiratory: symmetrical expansion,
bilateral clear breathing sounds
5.Cardiovascular: regular heart beat, no murmur
6.Gastrointestinal: flat, soft, no tenderness, no superficial vein engorgement,
normactive bowel sound, normal liver span
7.Genitourinary: no flank knocking pain
8.Metabolic: no thyroid enlargement, pitting edema, hand tremor
9.Musculoskeletal: bilateral side limbs weakness, no bone pain
10.Hematologic: no petechia, ecchymosis
<Neurological Examinations>
1.Consciousness: clear
2.JOMAC: judgement: intact, orientation:intact; meomory:intact;abstract:intact
3.Speech: fluent
comprehension: could obey three steps order
expression: grossly intact
fluent: no impaired
repetition: grossly intact
naming: grossly intact
spotaneous verbal output: intact(+)
4.Swallowing: oral feeding
oral phase: intact holding, mastication coordination, tongue movement
laryngeal phase: no choking to liquid
esophagus phase: no UES dysfunction or GERD
5.Cranial Nerves
CN II: Visual acuity & Visual field: grossly intact
Pupils: isocoric; Light reflex: +/+
CN III-IV-VI: EOM: free and full; No ptosis
CN V: Facial sensation: symmetric and intact
Mastication:grossly intact; Corneal reflex R/L:+/+
CN VII: Left central facial palsy, mild
CN VIII: No obvious hearing impairment; No nystagmus
CN IX,X: Velar elevation: symmetric; Gag reflex: +/+
CN XI: SCM/Trapezius: grossly intact
53
CN XII: Tongue deviation to left
6.Motor: Brunnstrom's stage- LUE proximal/distal: Brun. stage V/V
LLE: Brun. stage IV
7.Deep Tendon Reflex: increased over left side
8.Spasticity: MAS 0 over left limbs
9.Sensation: paresthesia / hypoesthesia / hyperesthesia
10.Coordination: Finger to Nose test: no obvious dysmetria
11.Sphincter: continent
<Functional status> Rolling to R/L: D/I

Sitting up: moderate assistance
Sitting balance S/D: F/F
Standing up: maximal assistance
Standing balance S/D: F-/P
Ambulation: try ambulatoin with maximal assistance
Transfer: Maximal assistance
<Functional Independence Measure, FIM>

(1)Self care
A. Eating 4
B. Grooming 1
C. Bathing 1
D. Dressing upper body/lower body 1/1
E. Toileting 1
(2)Sphincter control
G. Bladder management 1
H. Bowel 1
(3)Transfer
I. Bed, chair, wheelchair 1
J. Toilet 1
K. Tub,shower 1
(4)Locomotion
L. Walk/wheelchair 1
M. Stairs 1
-------------------------------------------Motor subtotal score: /91
(5)Communication
N. Comprehension 2
O. Expression 1
(6)Social cognition
P. Social interaction 1
Q. Problem solving 1
R. Memory 1
-------------------------------------------Cognitive subtotal score: /35
Total FIM: /126
實驗室數據
1010504(1045) 1.010 10.300 26.000
54
1010504(1045) 4.060 6.400 13.000 37.500 215.000
32.000 34.800 92.100 12.600 15.900
MPV
8.300
--------------------------------------------------------------------------------
1010504(1045) 13.000 120.000 0.800 141.000 3.800
105.000 20.000 20.000 76 STAGE 2
■ 入院診斷
1. P-com aneurysm rupture s/p with bilateral hemiplegia and dysarthria
2. Respiratory failure s/p tracheostomy tube
3. Hydrocephalus s/p ventricle-peritoneal shunt
4. Type 2 diabetes mellitus
5. Asthma
■ 主要計劃
Plan :
1. PT: therapeutic exercise, facilitation training, and tilting table training
2. OT: postural training, ADL training, and functional training of bilateral
limbs
3. ST: verbal production, augmentative comprehension training, and oral training
Goal :
1. Wheelchair bound, walk with cane, quadricane under assistance.
2. ADL as independent as possible, such as eating and light hygiene.
3. Balanced bladder.
4. Family education for preventing complications, such as pneumonia, pressure
sore and joint contracture.
■ 精神層面
Well family support
Admission Note（泌尿科）
55
病歷號
碼:00000000
衛生福利部豐原醫院姓名:王 00
住院序號:00000000000 床號:
-------------------------------------------------------------------------------------
§ 日期︰000/00/00 § 時間︰00:00 § 醫師︰ooo
------------------------------------------------------------------------------------
■基本資料
Name (姓名)：王 00
Occupation(職業)：商
Place of residence(住處)：東勢鎮東崎街 252 巷 3 號 6F
■主訴
Painful swelling left scrotum for 3 days
■現況病史
This 38 years old man denied prior systemic disease before. He was in his usual
health status until 4 days before admission. Left painful swelling of scrotum was
reported.
Tracing back to his history, he denied ilegal sexual behavior with hooker before
and had only one sexual partner (his wife) only. The last intercourse was about 2
weeks ago and last self-ejaculation (with blood-tinged semen) was about one week ago.
He started suffering from frequency, urgency, dysuria during 1-3 days after last
ejaculation. Painful left scrotum was also reported. He then came to our URO OPD on
4/30 and received wincef treatment. Urine culture collected at that time showed no
growth. Pain subsided after antibiotic but relapsed on 5/3. He came back to our OPD
for medications. Fever with heavy chills was noted after home. He then came to our ED
for help. Vital sign: 38.6'C, 100bpm, 156/102mmHg at arrival. PE showed left swelling
scrotum and lab showed leukocytosis (20000) with left shifting but not significant
increased CRP. Under the impression of acute epididymitis, he then was admitted to
our ward for antibiotic treatment and surgical drainage if abscess formation.
■ 既往病史
Denied DM, hypertension or other systemic disease
■社會史
1. Alcoholic drinking : social
2. Smoking : 2ppd
■過敏史
56
■家族史
Non-contributory
Pedigree:　　　　　　　
　　　█─┬─○
　　　　　　　　　│
　　　　　　　┌─┴─┐
　　　　　　　○ □　
■系統回顧
1.Systemic: **fever
no body weight loss, easy-fatigue, change of appetite
2.Skin: no petechiae, purpura, skin rash, itching
3.HEENT: no blurred vision, strabismus, ocular pain, earache, otorrhea, hearing loss,
tinnitus, vertigo, nasal stuffiness, nasal discharge, nasal bleeding, gu bleeding,
sorethroat
4.Cardiovascular: no exertional chest tightness, orthopnea, syncope, palpitation
intermittent claudication
5.Respiratory: no dyspnea, cough, chest pain, hemoptysis
6.GI: no anorexia, nausea, vomiting, dysphagia, heart burn, acid regurgitation,
abdominal fullness, hunger pain, constipation, diarrhea, melena, change of bowel
habit, tenesmus
7.Urogenital:
**urinary frequency, **urgency, **dysuria,
no flank pain, hematuria, hesitance, impotence, nocturia, polyuria, oliguria.
8.Musculoskeletal: no arthralgia, muscle ache, weakness.
9.Metabolic: no heat or cold intolerance, easy thirsty
10.Nervous: no numbness, paresis, paralysis
■理學檢查
Consiousness: alert
Vital sign:BP: 144/87 mmHg, PR: 100bpm, RR:18cpm, BT:38.5 ℃
HEENT: Conjuctiva: not pale; Sclera: anicteric
pupil: (3/3), light reflex: +/+
Neck: supple
lymphadenopathy (-), jugular vein engorgement (-)
Kernig sign (-), Brudzinski sign (-)
thyroid: impalpable
Chest: symmetric expansion, no accessory muscle usage
Breath sound: bilateral clear, no crackle
Heart sound: regular heart beat, no auditory murmur
Abdomen: soft, distention
Bowel sound: normo-active
Palpation: no abdominal tenderness
liver/spleen: impalpable, Muphy's sign (-), McBurney's sign (-)
Extremity:
Upper: no palmar erythema
Lower: ROM: full, no pitting edema
Skin: fair turgor, intact, no rash, no wound or bedsore
left scrotum: swelling, mild erythematous, severe tenderness
57
實驗室數據
** 尿液檢查 **
1010503(1603) 8.000 1.020 - - 1.000
- - - +/- 0-2
0-5 0-5 - +/-
--------------------------------------------------------------------------------
1010507(0757) 0.930 9.500 30.800

1010503(1603) 4.820 20.800 15.300 43.300 300.000
31.700 35.200 89.900 90.000 6.200
0.100 0.100 3.600 13.700 16.400
MPV
7.300
--------------------------------------------------------------------------------
Date(Time) BUN(Blood) Creatinine Na 鈉(boold K 鉀(Blood) S-GPT(ALT)
1010503(1603) 14.000 1.040 136.000 3.300 30.000
C.R.P-Neph e-GFR 腎絲 STAGE
1.600 80 STAGE 2
Date(Time) Glucose(PC
1010503(1603) 130.000
--------------------------------------------------------------------------------
Date(Time):1010503(1603), Urin(Cathe
No growth
------------------------------------------------------------------------------
■ 入院診斷
Acute epididymitis, left
■ 主要計劃
1. On ward routine
2. antibiotic with cefazolin + gentamycin
3. follow up lab later
4. Ice packing for left scrotum
5. well explained to patient and his family about current condition and medical plan
■ 精神層面
Normal spirit
Orietation: fair
No dellusion or hallucination
58
醫師簽章：
○○○
Admission Note（耳鼻喉科）
病歷號碼:00000000
衛生福利部豐原醫院姓名: OOO
住院序號:00000000000 床號:
-------------------------------------------------------------------------------
----------
§ 日期︰000/00/00 § 時間︰00:00 § 醫師︰ooo
-------------------------------------------------------------------------------
-------------
■基本資料
Name (姓名)：OOO
Place of residence(住處)：臺中市豐原區南陽街 92 巷 59 號 3 樓
Relational past History(相關既往病史)：鼻中膈鼻道成形手術後
■主訴
59
snoring noted for 4 years.
■現況病史
This 55 year-old male with the past history of hypertension with
medication was admitted
via OPD due to snoring for 4 years. According to the statement of the patient
himself, he suffered
from snoring for a long time and the condition of snoring got worse in recent 4
years . He also
complained of hypersomnolence and dry throat in the morning. He went to our
hospital for help.
At our ENT OPD, enlarged tonsils (Gr II-III) and redundant soft palate were
found on physical exam.
Cephalometry and nasopharyngoscopy showed narrowed retro-palatal space.
Polysomnography was performed
and showed apnea-hypopnea index (AHI) 96/hr. Under the impression of 1)
obstructive sleep apnea and
2) chronic tonsillitis, he was admitted for further evaluation and surgical
treatment.
Throughout the whole course, there were snoring, hypersomnolence and dry
throat. There was
no frequent sore throat, purulent rhinorrhea, sneezing, or stridor.
■既往病史
1. DM: denied
2. Hypertension: with medication.
3. Other systemic disease: denied
4. Surgical history: septomeatoplasty on 98-06-10.
5. Hospitalization: once (due to septomeatoplasty)
■社會史
2. No Smoking
5. Occupation : business
■過敏史
■家族史
■系統回顧
1. Systemic: No fever, BW loss, easy-fatigibility, change of appetit or
dizzines
2. Skin: No petechiae, purpura, skin rash, or itching.
3. HEENT: ** snoring, hypersomnolence and dry throat**
60
No nasal obstruction, rhinorrhea, blurred vision ,
strabismus, ocular
pain, ear ache, hearing impairment, otalgia, otorrhea, tinnitus,
vertigo, nasal pain, gum bleeding, sore throat, odynophagia,
epistaxis,
husky voice, oral pain or ulcer.
4. Cardiovascular: No exertional chest tightness, PND, orthopnea, syncope,
palpitation, or intermittent claudication.
5. Respiratory: No dyspnea , cough, sputum, chest pain or hemoptysis.
6. GI: No anorexia, nausea, vomiting, dysphagia, heart burn, acid
regurgitation,
abdominal fullness, midnight pain, constipation, diarrhea, melena,
change
of bowel habit, tenesmus , or flatulence.
7. Urogenital: No flank pain, hematuria, urinary frequency, urgency, dysuria,
hesitancy, oliguria, small stream of urine, impotence, nocturia
o
polyuria.
8. Musculoskeletal: No bone pain, arthralgia, muscleache, or weakness.
9. Metabolic: No heat intolerance, cold intolerance, or thirsty.
10. Nervous: No numbness or paresis.
■理學檢查
Conscious: Clear
GCS: E4V5M6
Vital Signs: BP: 128 / 77 mmHg TPR: 36.0 ℃, 72 /min, 20 /min
INTEGUMENT: Normal skin turgor, No edema, eruption, petechiae, ecchymosis or
clubbing finger
HEENT: Conjunctiva: not pale
Sclera:Not icteric
No ptosis
Iscoric pupils with normal light reflex
Normal visual acuity
Ear: bil eardrum: intact
Nose: patent nasal cavity.
Oral cavity: smooth mucosa.
Tonsils: enlarged tonsils (Gr II-III)
Neck: Supple, no lympadenopathy , no JVE,
Thyroid gland: not enlarged
Larynx: no polyps or nodule, freely movable
CHEST: Bilateral symmetric expansion
Breath Sound: Clear
Percussion: Resonance
HEART: Regular heart beat, no murmur
ABDOMINEN: Flat, no scar, superficial vein engorgement
Active bowel sound, no bruits
Soft, no tenderness,
Normal liver and spleen span
EXTREMITIES: No edema or deformity; freely movable
EKG: Sinus rhythum
CXR: symmetric lung expansion
61
實驗室數據
1010429(1045) 1.010 10.100 26.000

1010429(1045) 4.060 6.400 13.000 37.500 215.000
32.000 34.800 92.100 12.600 15.900
MPV
8.300
Date(Time) BUN(Blood) Glucose(AC) Creatinine Na 鈉(boold) K 鉀(Blood)
1010429(1045) 15.000 120.000 0.800 141.000 3.800
105.000 20.000 20.000 76 STAGE 2
■ 入院診斷
780.53 Obstructive sleep apnea (OSA)
　　　 474.00 chronic tonsillitis
■ 主要計劃
1. On ENT routine
2. Check CBC/DC, SMA, EKG, CXR
3. Arrange uvulopalatopharyngoplasty (UPPP)
4. IV fluid supply
5. Prophylatic antibiotic therapy
6. Analgesic was given
7. Plaslloid therapy
8. Methasone therapy
9. Explain and education
■ 精神層面
Well family support
62
出院病歷摘要（內科）
(1)醫院代號及名稱 (2)姓名 (3)身份證號 (4)出生日期 (5)病歷號碼
0136010010 衛生署豐原醫院 ○○○ 0000000000 00 年 00 月 00 日 00000000
(6)轉入醫院 (7)地址 000000000 (8)流水編號
(9)入院日期 00 年 00 月 00 日胸腔科病床號碼 2517
(10)轉科(床) 年月日病床號年月日 - 病床號
(11)出院日期 00 年 00 月 00 日住院天數計日
入 1. Hemoptysis, R/O lung cancer, R/O lung abscess
(12) 院 2. Benign prostate hyperplasia s/p transureteral resection of prostate
診
斷出 1. Lung abscess, RLL
院 2. Benign prostate hyperplasia s/p transureteral resection of prostate
(13)主訴 Intermittent cough with bloody sputum for one month
The patient is a 62-year-old male with the past history of (1)Old CVA of
(14)病史 SAH and ICH within long-term bed-ridden status and seizure sequelae (2)s/p
tracheostomy (3)Hypertension. The above diseases were regularly followed up
in our CM OPD. He was relatively stable until this Monday.
The present illness could be traced back to 4 days ago when fever was noted
by the home-care nurse. Thus, he was brought to our FAM OPD for assistance.
63
Pneumonia was impressed at that time and Curam was prescribed. The
fever subsided after that. However, shortness of breath occurred last
night. Besides, much sticky sputum accumulation was also noted. Due to the
persistence of the above symptoms, he was then brought to our ER.
In our ER, the physical examination revealed coarse breathing sound and
fever. The phlebotomy report showed leucocytosis with N-Seg. predominant. The
CXR disclosed ground glass opacity over both lower lungs. Under the
impression of BLL pneumonia with respiratory failure s/p Tr. + MV, he was
then arranged to admit to our ICU for further evaluation and treatment.
Past History：
1. DM (-), HTN (-), COPD (-), Asthma (-), TB (-), CV disease (-), CVA (-)
2. Other major systemic disease：denied
3. Surgical history：benign prostate hyperplasia s/p transureteral resection
of prostate on 00/00/00 and 00/00/00
Personal History & Allergic History :
1. Alcohol consumption：denied
2. Smoking：1PPD for 50 years and has quit for 4 years
3. Allergy：denied drugs or food allergy history
Family History：Non-contributory
(15) Review of system：

體 1. Systemic ： fever (-), BW loss (-), easy-fatigibility (-), change of
檢 appetite (-), dizziness(-)
發 2. Skin：petechiae (-), purpura (-), skin rash (-), itching (-)
現 3. HEENT：blurred vision (-), strabismus (-), ocular pain (-), ear ache (-),
otorrhea (-), hearing loss (-), tinnitus (-), vertigo (-), nasal stuffiness
(-), nasal discharge (-), nasal bleeding (-), gum bleeding (-), glossitis
(-), sorethroat (-)
4. Cardiovascular ： exertional chest tightness (-), PND (-), orthopnea (-),
syncope (-), palpitation (-), intermittent claudication (-)
5. Respiratory：dyspnea (-), cough (+), chest pain (+), hemoptysis (+)
6. GI：anorexia (-), nausea (-), vomiting (-), dysphagia (-), heart burn (-),
acid regurgitation (-), abdominal fullness (-), hunger pain (-), midnight
pain (-), constipation (-), diarrhea (-), melena (-), change of bowel habit
(-), small caliberofstool (-), tenesmus (-), flatulence (-)
7. Urogenital：flank pain (-), hematuria (-), urinary frequency (-), urgency
(-), dysuria (-), hesitancy (-), small stream of urine (-), impotance (-),
nocturia (-), polyuria (-), oligouria (-)
8. Musculoskeltal：bone pain (-), arthragia (-), muscleache (-), weakness (-)
9. Metabolic：heat intolerance (-), cold intolerance (-), thirsty (-)
10. Nervous：numbness (-), paresis/plegia (-)
Physical examination：
General appearance ： a well-developed male with acute ill-looking, no
respiratory distress
Consciousness：clear, GCS-E4V5M6, JOMAC-intact
Vital signs：BP-135/80 mmHg, BT-36.2°C, PR-95/min, RR-18/min
Integument ： normal skin turgor, edema (-), eruption (-), pethechia (-),
ecchymosis (-), clubbing finger (-), cyanotic nail (-)
HEENT：
Head-normal skull configuration and hair distribution, exophthalmos (-),
ptosis (-)
Eyes-Conjuctiva pale (-), sclera icteric (-), EOM intact, normal visual
acuity and color perception, Pupils isocoric (+) 3mm/3mm, light reflex R/L:
(+/+)
64
Ears-discharge from ears (-), hearing impairment (-)
Nose-normal shape, deviation of septum (-), polyps (-), patent of
airway, tenderness of sinus (-), congestion (-), rhinorrea (-), post-nasal
dripping (-)
Mouth-cyanotic lips (-), cold sores (-), oral ulceration (-), tongue
deviation (-), swelling or erythematus change tonsils (-), Throat-injected
(-), gum bleeding (-)
Neck：supple (+), LAP (-), JVE-(-), goiter (-), palpable mass (-)
Chest：
(1) Inspection ： normal contour of ribs cage with symmetric expansion,
kyphosis (-), scoliosis (-)
(2) Palpation：normal tactile fremitus, subcutaneous emphysema (-)
(3) Percussion：resonance, abnormal dullness (-)
(4) Auscultation ： wheezing (-), rhonchi (+) over right upper lung field,
crackle (-)
Heart：
(1) Inspection：no visible PMI
(2) Palpation：thrill (-), heave: (-)
(3) Percussion：normal shape
(4) Auscultation：RHB, no murmur
Abdomen：
(1) Inspection：flat shape, superficial vein engorgement (-), OP scar (-)
(2) Auscultation ： Normal active bowel sound, gastric succussion (-), bruits
(-)
(3) Palpation ： soft, tenderness (-), rebounding tenderness (-), liver and
spleen not palpable, mass palpable (-)
(4) Percussion：normal liver and spleen span, shifting dullness (-)
Back and spine ： normal curvature, tenderness (-), root pain (-), knocking
pain (-)
Anus and rectum：no rectal mass
Extremities and joints ： free moveable, pitting edema (-), clubbing finger
(-), tremor (-), petechia (-), purpura (-), cyanosis (-)
Peripheral pulsation：
CA BA RA FA PA DPA PTA
RIGHT +++ +++ +++ +++ ++ ++ ++
LEFT +++ +++ +++ +++ ++ ++ ++
Nervous system ： Mentality-well orientation, registration, attention and

calculation
Cranial nerves-intact
Motor-MP-upper 5/5, lower 5/5
DTR-BJ ++/++, TJ ++/++, KJ ++/++
Babinski sign -/-, rigidity (-), spasticity (-)
Sensory-symmetric pinprick, ligh touch, and joint position
Coordination-F-T-N OK, H-T-S OK, RAM OK
Tendem walking and Romberg test OK
(16) 手術日期
及方法(包括手 Nil
術發現)
After admission, series of examinations were performed, including (1)Chest
(17)住院治 CT scan ：necrosing tissue with infectious infiltration over RLL. (2) Sputum
療經過 cytology：negative for malignancy. (3) Sputum acid fast stain：not found (4)
tumor markers were within normal range were preferred the diagnosis of lung
65
abscess, therefore, we used empiric antibiotics (clindamycin 600 mg
q6h and GM 160 mg qd) + IV fluid supplement for lung abscess, RLL.
Then, follow-up CXR and clinical symptoms improved. After we shift the
antibiotics to clindamycin 600 mg q6h and clinical condition stable. He was
discharged and suggested OPD follow-up.
(18)合併症 Nil
(19)
檢
查
記
錄
一般檢查(如：尿液、糞便、血液、生化、細菌…之檢查)
**血液學檢查**
1. CBC：(Date 00/00/00)
WBC：6.4 K/UL (Segment/Lymphocyte 70/16), Hb 12.4 g/dl, MCV 96.8fl, HCT 37%,
PLT 229K/UL
2. PT：12.6 sec, INR：1.29, APTT：28.1/ 26
**一般生化學檢查**
SMA：(Date 00/00/00)
GPT：28 IU/L, BUN/Cr：19.4/1.6 mg/dl, LDH：426IU/L, Na/K：141/3.3 mmol/l
Glucose PC：104mg/dl
**尿液檢查**
Urinalysis：(Date 00/00/00)
Sugar -, Ketone body -, Sp. Gr 1.013, OB ++, PH 7.0, protein -, Urobilinogen
-, Nitrite -, WBC 0-1 HPF, RBC 20-25 HPF, Epithelial cell 0-1 HPF, Bacteria -
**糞便檢查**
(Date 00/00/00) OB (-)
**免疫學檢查**
(Date 00/00/00) (1) SCC ：0.5 (2) CEA ：1.94 (3) CA-199：7.52 (3) CA-125 ：39
(4) CA-135：20
**細菌學檢查**
(Date 00/00/00) (1) sputum culture：normal flora (2) (Date 00/00/00)：sputum
acid fast stain: not found X II sets (3) (Date 00/00/00)：sputum Gram stain：
WBC>25/LPF, EP< 25/LPF G(+) cocci：++
**心電圖**
ECG：sinus tachycardia
特殊檢查(如：超音波、內視鏡、呼吸、循環、神經、泌尿、耳鼻喉、眼…之檢查)
Date(Time):1010526(1015), 朴卜勒氏彩
1. Dilated LV chamber size , with hypokinesia over LV anterior and
anterolateral walls ; akinesia over interventricular septum, LV inferior
and posterolateral walls ; LVEF less than 40%
2. Thickened aortic leaflets with minimal aortic regurgitation
3. Mild mitral regurgitation
4. Mild tricuspid regurgitation with peak pressure gradient 16 mmHg
5. No pericardial effusion
66
1. CXR (Date 00/00/00)： tortous aorta with calcified wall and normal
heart size, infiltration of LUL and RLL
(20)放射線報 2. Chest CT scan (Date 00/00/00)：infectious process at superior segment of
告 right lower lobe is mostly likely, minimal amount of pleural effusion over
right lung
(21) 病理報告
( 包括病理發 Sputum cytology (Date 00/00/00)：negative for malignancy
現)
(22)其他 Nil
(23) 出院時情
改門診治療
況
(24)出院指示
處置名稱次劑量單位服法天總量單位
Medicon-A Cap 1/1 粒 QAPH 7 28/1 粒
THROUGH 2/1 粒 1NHS 7 14/1 粒
MGO 250 mg 2/1 粒 TID 7 42/1 粒
STROCAIN 5mg 1/1 粒 TID 7 21/1 粒
Clindamycin 300 mg 2/1 粒 QID 7 56/1 粒
主治醫師蓋章：○○○ 住院醫師蓋章：○○○
67
出院病歷摘要 (外科)
0136010010 衛生署豐原醫院 ○○○○(女) 00000000 00/00/00 00000000
(6)轉入醫院 (7)地址 ○○○○○○○○○ (8)流水編號
(9)入院日期 101 年 00 月 00 日肝膽腸胃科 1700-00 病床號碼
(10)轉科(床) 101 年 00 月 00 日外科 1700-00 病床號 101 年 00 月 00 日外科 1ICU-00 病床號
(11)出院日期 101 年 00 月 00 日住院天數計 00 日
1.Borrmann type III advanced gastric cancer
2.Gastric ulcers
入
3.Hypertensive cardiovascular disease
院
(12) 4.Af
診 5.Ileus with stool impaction
斷 1. Borrmann type III advanced gastric cancer, antrum

出 -> s/p radical subtotal gastrectomy + B-II gastrojejunostomy on 101/05/17
院 2. Gastric ulcers
3. Hypertensive cardiovascular disease with Af
(13)主訴 Intermittent abdomen pain for 3 months.

(14)病史
This 00 y/o woman is a case of hypertension and arrhythmia with Af , and she
was regular follow up at LMD more than 20+ years.
According to the statement of the patient and her family, she suffered
from intermittent epigastric pain for 3 months. There was denied body weight
loss, fever, diarrhea or vomiting. In this March, she visited 協和 hospital
and endoscopy was suggested but she was refused. However, anorexia and easy
abdomen distension were developed in recent weeks. So endoscopy was arranged
today, which revealed diffuse ulcerative masses lesion extending whole antrum
and anaularis to low body and biopsy was done. Under the impression of
Borrmann type III advanced gastric cancer,antrum, angularis and low body s/p
biopsy, she was transferred to our hospital form 協和 hospital and admission
for further evaluation and treatment.
(15)體檢發現【The Major Findings of Physical Examination On Admission 】

●Consciousness：alert
●Coma Scale：E(4)M(6)V(5)
●General appearance: female patient with chronic ill, no cardiopulmonary
distress
●Vital Signs：BP=145/83mmHg, PR=105/min, RR=18/min, BT=36.2℃
●HEENT：
◇Head：no open wound, no scalp hematoma, no hair loss, no scar, no
tenderness, no cold sweating,
◇Eye：no abnormal deviation of eye-ball, no exophthalmos. no ptosis,
Pupil：isocoric. Size＆Light Reflex：L3mm(+)/R3mm(+)
Conjunctiva：pink, not pale,(no anemic change).
◇Ear：intact and clear auditory cannel, no discharge.
◇Nose：No epistaxis, no rhinorrhea, no polyp, no deformity of nasal septum.
◇Neck：supple, no stiffness, no motion-limited, no jugular vein engorgement.
68
No lymph node adenopathy, No palpable mass, No open
wound/Tenderness.
No using of acceaaory-aspiratory muscles. No Central Venous Catheter noted.
●Chest：
no using of accessory-respiratory muscle,
symmetric expansion, intermittent shortness of breathing,
︵ no subcutaneous emphysema, no open wound of chest wall.
∕ ﹨
｛`︷'｝Heart sound：Irregular heart beat with Gr-II systolic murmur.
╰─╯ Breathing sound：Bilateral coarse breathing sound.
╴ ∕ ﹨＿ ●Abdomen：
∕ ＼〒／ ﹨ Soft, not guarded. Scaphoid in appearance.
﹨ ∕ Hypo-active bowel sound
﹨ ⊙ ⊙∕ Liver/Spleen: non-palpable,
）︾ˇ︾（ Tenderness：over A2 area
∕ ﹨ Rebunding pain：(-)
∕ x ﹨ Palpable mass：(-)
▏ ｜
▏ ∕︶﹨ ｜
●Back：Knocking pain:(-) Radiation pain:(-), No compression sore wound.

●Extremities：Full range of motion, no deformity
(16)手術日期及 101/05/17 72047B 次全胃切除及淋巴清除及腸胃重建
方法( 包括手術
發現)
(17)住院治療經
過 Patient had received supportive treatment after admission. Surgical
department was consulted for operation and CV department was consulted for
pre-operative evaluation. Radical subtotal gastrectomy + B-II
gastrojejunostomy were performed on 101/05/17. After surgery, she was
transferred to SICU for intensive care. NPO with IV fluid supplement was given
and prophylactic antibiotics were used with Stazoline for 1 week course.
Extubation of endotracheal tube was done on the next day of surgery and she
was transferred to ordinary ward on 101/05/20 due to general stable condition.
Wound healed well and all stitches were removed on 101/05/24. She had tried
water and then soft diet since 101/05/25. No anastomotic leakage was noted via
CWV drain. Due to general stable condition, she was discharged on 101/05/28
and OPD follow-up was arranged.
(18)合併症 no fever, no nausea/vomiting, no wound infection
(19) ** 尿液檢查 **
檢 Date(Time) PH 比重檢查蛋白質定性糖定性檢查尿膽素原檢
1010519(0704) 5.500 1.014 - - 0.100
查膽紅素苯酮體檢查亞硝酸鹽檢 OB RBC
- - - 2+ 11-20
紀 WBC Epithelial Bacteria WBC(定性)
0-5 0-5 - -
錄

1010504(1329) 7.000 1.004 - - 0.100
69
- - - - 0-2
0-5 0-5 - -
-----------------------------------------------------------------------
1010521(2253) 8.800 10.100 211.000 83.600 9.600
Baso Eosin MONO
0.000 0.500 6.300

1010518(1517) 4.260 11.900 11.100 33.900 190.000
26.000 32.700 79.400 84.300 8.800
0.100 0.000 6.800 14.900 16.200
MPV
10.300

1010517(1458) 3.920 11.500 10.200 31.300 162.000
26.000 32.500 79.700 87.000 8.000
0.000 0.000 5.000 14.900 16.600
MPV
9.700

1010517(1408) 1.070 10.400 21.700

1010517(1408) 4.320 5.900 11.300 34.600 178.000
26.100 32.700 79.900 14.600 15.900
MPV
10.700

1010514(1256) 7.100 11.300 157.000 73.300 15.900
Baso Eosin MONO
0.500 1.100 9.200

1010511(1331) 4.950 8.400 12.900 39.500 131.000
26.100 32.700 79.800 14.700 17.200

MPV
10.400

1010504(1329) 5.500 12.500 229.000 66.400 23.000
Baso Eosin MONO
0.300 1.400 8.900
70
-----------------------------------------------------------------------
** 一般生化學(免疫)檢查 **
Date(Time) BUN(Blood) Ca(Blood) Creatinine Na 鈉(boold K 鉀(Blood)
1010521(2253) 10.000 8.100 0.700 133.000 3.800
S-GOT(AST) S-GPT(ALT) 白蛋白 Alb C.R.P-Neph e-GFR 腎絲
16.000 6.000 2.000 18.600 80
STAGE
STAGE 2
Date(Time) pH PCO2 PO2 HCO3act tCO2

1010518(1914) 7.424 33.800 202.800 21.600 22.700
BE(vt) O2SAT
-2.000 99.400
Date(Time) BNP 利鈉激

1010518(1822) 198.000
Date(Time) 肌酸磷化脢 CK-MB Troponin I CK-MB mass

1010518(1822) 243.000 3.700 <0.01 1.500
Date(Time) Prealbumi
1010518(1858) 14.000

1010518(1517) 7.559 22.700 168.500 19.800 20.500
BE(vt) O2SAT
-0.300 99.400

1010518(1517) 13.000 171.000 8.200 0.860 138.000
K 鉀(Blood) Cl(Blood) S-GOT(AST) S-GPT(ALT) C.R.P-Neph
4.500 110.000 23.000 11.000 5.800
e-GFR 腎絲 STAGE
63 STAGE 2

1010517(1458) 7.548 24.200 190.400 20.600 21.300
BE(vt) O2SAT
0.100 99.500

1010517(1458) 13.000 160.000 7.300 0.580 140.000
K 鉀(Blood) Cl(Blood) S-GOT(AST) S-GPT(ALT) 白蛋白 Alb
3.400 113.000 19.000 11.000 2.200
0.400 100 STAGE 1

1010517(1408) 20.000 112.000 0.740 141.000 4.600
S-GOT(AST) S-GPT(ALT) e-GFR 腎絲 STAGE
23.000 15.000 75 STAGE 2

1010514(1256) 24.000 8.600 0.780 137.000 4.000
71
S-GOT(AST) S-GPT(ALT) C.R.P-Neph e-GFR 腎絲 STAGE
23.000 16.000 10.200 71 STAGE 2

1010511(1331) 13.000 102.000 9.000 0.900 137.000
K 鉀(Blood) Cl(Blood) S-GOT(AST) S-GPT(ALT) 膽紅素總量
4.300 102.000 34.000 14.000 0.800
直接膽紅素白蛋白 Alb e-GFR 腎絲 STAGE
0.150 3.300 60 STAGE 2
Date(Time) Triglyceri P(Blood)磷鎂 Mg (Mag Taansferri Prealbumi

1010511(1331) 108.000 3.700 2.630 276.500 19.000
Date(Time) α－胎兒蛋 CEA 癌胚胎 HBsAg- HBsAg-酵素 Anti-HCV 篩

1010507(0913) 3.190 1.700 Non-Reacti 0.010 0.050

1010504(1329) 13.000 129.000 9.300 0.800 141.000
K 鉀(Blood) S-GOT(AST) S-GPT(ALT) Alkalinpho 乳酸脫氫脢
4.300 29.000 14.000 101.000 155.000
白蛋白 Alb e-GFR 腎絲 STAGE
3.400 69 STAGE 2
-----------------------------------------------------------------------
** 微量元素/藥/毒物測定 **
Date(Time) Digoxin
1010504(1806) 0.600
-----------------------------------------------------------------------
1010516(0713) O Positive
-----------------------------------------------------------------------
No growth
-----------------------------------------------------------------------
特殊檢查(如:超音波.內視鏡.呼吸.循環.神經.泌尿.耳鼻喉.眼……之檢查)
Date(Time):1010507(1201), 超音波心臟
1.MILD CONCENTRIC LVH. LA DILATATION.
2.BORDERLINE LV GLOBAL PERFORMANCE, LVEF = 44.8%
3.MILD TO MODERATE AR,MILD MR.
4.MILD PR, MODERATE TR.
5.NO PERICARDIADL EFFUSION.
-----------------------------------------------------------------------
Date(Time):1010504(1443), 腹部超音波
SONAR FINDINGS:
1. Liver: Coarsening echogenicity of liver with suspected one isoechoic
tumor 2.7cm in size over Rt lobe
2. Intrahepatic Duct: Normal
3. Common Bile Duct: Normal
4. Gallbladder: Normal Size
5. Portal Vein: Normal
6. Pancreas: Normal
7. Spleen: Normal
8. Kidney rt: Normal lt: Normal
9. Aorta: Normal
72
10.I.V.C: Normal
11.Others:
DIAGNOSIS:
Hepatic tumor,Rt, R/O metastasis
Parenchymal liver disease
SUGGESTION:
CT
(20)放射線報告 Date(Time):1010521(2253), Portable C

Portable chest:
> S/p NG tube insertion.
> S/p central venous catheter insertion, via right neck.
> Cardiomegaly.
> Drainage catheters at the abdomen.
> DJD change of T-spine,
> Prominent bilateral central pulmonary vessels and exaggerated lung markings
over both lungs. Recommend clinical check to rule out heart failure, pulmonary
congesion, or edema.
> Both CP angle blunting, suspect minimal pleural effusion or chronic pleural
change.
> Recommend correlate with clinical symptom and follow up.
-----------------------------------------------------------------------
Date(Time):1010504(1443), abd.-/+
The pre- and post-enhanced whole abdominal CT showed:
> IV omnipaque
> normal attenuation of liver and spleen without focal lesions
> normal gallbladder and bil. IHDs
> no focal lesion at pancreas and both kidneys/ adrenal glands

> suspicion of gastric wall thickening at greater curvature of high body
> no evident retroperitoneal or pelvic LAP
> a small ascites suspicion of gastric wall thickening at greater curvature of
high body, and endoscopy is suggested
-----------------------------------------------------------------------
(21)病理報告 Date(Time):1010517(1245), 冰凍切片檢, 免疫組織化, 一般病理檢

-----------------------------------------------------------------------
冰凍切片診斷 (Original frozen section report dated 2012-05-17):
1. Serosa of high body, frozen section ---- Benign mesenchymal tumor with
focal dystrophic calcification.
2. Distal (duodenal) resection margin, frozen section ---- Negative for

malignancy.
3. Proximal (gastric) resection margin, frozen section ---- Negative for

malignancy.
Comment: Pathologist Dr.舒惠芬 is responsible for frozen section diagnosis

of specimens 1 and 2. Pathologist Dr.賈永芳 is responsible for
frozen section diagnosis of specimen 3.
-----------------------------------------------------------------------
The specimens are submitted in fresh state for frozen section in 3 bottles,
and labelled as 1) serosa of high body, 2) distal (duodenal) resection
73
margin, and 3) proximal (gastric) resection margin.
Bottle 1, labelled "serosa of high body", consists of a small nodule

measuring 0.5 x 0.4 x 0.2 cm in size. On cut section, it shows tan-white
and elastic to rubbery firm cut surface. It is bihalved, and totally
submitted.
Bottle 2, labelled "distal (duodenal) resection margin" consists of a ring

of duodenal tissue measuring 2.5 x 2 x 0.5 cm in size. Grossly, it is
pink-tan and elastic. All for section.
Bottle 3, labelled "proximal (gastric) resection margin", consists of an

elongated strip of gastric tissue measuring 10.5 x 0.8 x 0.5 cm in size.
Grossly, it is pink-tan and elastic. All for section after sectioning
(except for adjacent fatty tissue, which is submitted for permanent
section).
All for section after sectioning, and labelled as follows:

A (FS1): frozen section of high body serosa
B (FS2): frozen section of distal (duodenal) resection margin
C-D (FS3a-b): frozen section of proximal (gastric) resection margin
E: fatty tissue lying adjacent to proximal (gastric) resection margin
Jar: 0
診斷醫師: 舒惠芬病解專醫字第 000209 號
-----------------------------------------------------------------------
Date(Time):1010507(1559), 第三級外科, 一般病理檢
Stomach, antrum, angularis, and low body, endoscopic biopsy ---- Tubular
adenocarcinoma, well to moderately differentiated, with surface ulceration.
-----------------------------------------------------------------------
The specimen submitted consists of 7 tissue fragments measuring up to 0.2 x
0.2 x 0.1 cm in size, fixed in formalin.
Grossly, they are grayish-white and elastic.
All for section. Jar: 0
Microscopically, section shows fragments of well to moderately

differentiated tubular adenocarcinoma comprised of neoplastic glands
arranged in mixed tubular to cribriform glandular pattern, with surface
ulceration, inflammatory exudate, and associated with mild to moderate
desmoplasia, as well as variable mixed acute and chronic inflammatory
infiltrate in lamina propria.
In addition, a piece of non-neoplastic antral type muosa is included, which

shows chronic superficial gastritis with mild foveolar hyperplasia, and
areas of intestinal metaplasia. No Helicobacter pylori infection is seen.

-----------------------------------------------------------------------
74
通知:1010504 15:52 楊聰鎰一般會診心臟血管科回覆:1010504 17:53 白錫彥
(22)其他 Dear DR:
This 00 Y/O madam was admitted due to advanced gastric CA.
She had history of HCVD, and Af, on rx in PU-TI Hospital.
Af with SVR, and cardiomegaly were noted.
The discussions:
1.CV impression is HCVD, AR, Af with SVR.
2.Check digoxin level st.
3.Lasix (40) 1/2# qd, Capoten(25) 1/2# bid, ismo 1# bid.
4.Echocardiography on call w1 AM.
*** Thanks.
通知:1010504 15:55 楊聰鎰一般會診外科回覆:1010504 17:08 匡勝捷

TO DEAR DR:
A CASE OF HIGHLY SUSPECTED ADVANCED GASTRIC CA NOTED FROM
UGI SCOPE. I WOULD LIKE TO VISITED THIS PATIENT AND
EXPLAIN THE SURGICAL DETAILS TO THE PATIENT AND HER FAMILY
AFTER ALL PRE-OPERATIVE STUDY BEING COMPLETED. THANKS FOR
YOUR CONSULTAION REUQEST.
(23)出院指示 ■改門診治療
(24)出院情況
處---------置----------名----------稱次劑量單位服法天總---量單位
MgO 250mg(氧化鎂錠) 2/ 1 粒 TIPO 3 18/ 1 粒
Kascoal 40mg(加斯克兒錠) 1/ 1 粒 TIPO 3 9/ 1 粒
!Lanoxin 0.25mg(隆我心錠) 1/ 1 粒 QDPO 3 3/ 1 粒
Nadis 40mg(納迪斯錠) 1/ 2 粒 QDPO 3 3/ 2 粒
Coxine 20mg(冠欣錠) 1/ 1 粒 BIPO 3 6/ 1 粒
主治醫師蓋章：○○○ 住院醫師蓋章：
75
出院病歷摘要 (小兒科)

0136010010 衛生福利部豐原醫院王 00 00000000 00/00/00 007*3*4*
(6)轉入醫院 (7)地址 000000000 (8)流水編號
(9)入院日期 100 年 09 月 08 日小兒科 1523-1 病床號碼
(10)轉科(床) 年月日科病床號年月日科病床號
(11)出院日期 100 年 09 月 12 日住院天數計 5 日
(12) 入 1. 558.9 其他非傳染性胃腸炎及大腸炎

診院 2. 780.6 發燒
出 1. 009.0 infectious gastroenteritis

斷院 2. 780.6 fever
(13)主訴 fever for 3 days and watery diarrhea for 2 days

(14)病史 This 9m/o boy without past medical history was admitted via PER due to fever off
and on for 3 days and watery diarrhea with poor intake for 2 days. According to
his family's statement, he suffered from fever since 3 days ago, diarrhea was also
noted with blood and mucus in the stool. Although he was treated at LMD, but in
vain. Fever and diarrhea persisted. So he was sent to our PER for help. The
labotory data show highly elevated CRP. And then he was admitted to our ward for
further evaluation and management due to AGE and dehydration.
Throughout the whole course, there were fever, watery diarrhea but no vomiting
or abdominal pain; there were no cough, rhinorrhea, cyanosis, short of breath,
frequency urgency, limbs weakness, or skin rash.
(15)體檢發現 General appearance: Acutely ill
Conscious: alert, Activity:weakness
Measurement:BW: 8.5 kg
Vital sign: BT: 37.7 ℃; HR:128 /min ; RR: 29 /min
HEENT: lips
Head: no facial abnormality
Eye: conjuctiva: not injected ;sclera: no icteric
76
Nose: no deformity
Thorat: * injected, no vesicle, no ulcer
Neck: supple,no lymphadenopathy
Chest: no retraction
Breathing sound:BS coarse,no wheezing, no rhonchi, no rales
Heart: RHB, no murmur
Abdomen: soft with mild distension ,abdominal pain
Hyperactive bowel sound,no mass palpable, no hepatomegaly,no splenomegaly
,no muscle guardening , no rebounding pain, no distention, tympanic on
percussion
Extrimities: freely movable, no pitting edema,no vesicle
Neurological examinationL:DTR all ++ Muscle power :all 5
no Bruzinski sign, no Kernig sign
Anus: patent Genitalia: Normal in appearance
Back: Grossly normal,no knocking pain
Skin: decreased skin turgor,no rash,petechiae
(16)手術日期
及方法 ( 包括 nil
手術發現)
(17)住院治療
經過 After admission, Rocephin 400 mg i.v. was given q12h since 9/8 night under the
impression of infectious enterocolitis, suspect salmonellosis, Then his fever
improved gradually. His stool routine showed OB 3+ but his urine, stool and blood
culture showed no significant bacteria growth. Although his stool Rota virus Ag
test was Positive, we kept Rocephin until 9/11 night due to salmonellosis can't be
excluded. When his diarrhea improved, the patient was discharged on 9/12 morning
and we prescribed oral cefspan for 4 days and appointed pediatric OPD follow up .
(18)合併症 Nil
** 尿液檢查 **
(19) Date(Time) PH 比重檢查蛋白質定性糖定性檢查尿膽素原檢
檢 1000908(1834) 5.500 1.020 - - 0.100
查 - - - +/- 0-2
紀 0-5 0-5 - -
--------------------------------------------------------------------------------
錄 ** 糞便檢查 **
Date(Time) OB Consistenc Color Mucus PUS
1000908(1213) 3+ Soft Yellow - -
Blood RBC WBC Parasite
- - - Not found
--------------------------------------------------------------------------------
Date(Time) W.B.C 白血 N-Seg Lymph Baso Eosin
1000909(2152) 10.600 13.000 67.000 1.000 1.000
MONO N-Band Myelo Atypical L
14.000 2.000 1.000 1.000

1000908(1213) 5.110 10.500 11.700 35.800 280.000

77
22.900 32.700 70.100 35.900 48.700
0.100 0.000 15.300 22.900 18.500
MPV
7.700
--------------------------------------------------------------------------------
1000909(2152) 7.000
Date(Time) Glucose(AC Na 鈉(boold K 鉀(Blood) C.R.P-Neph

1000908(1213) 128.000 138.000 4.400 14.800
--------------------------------------------------------------------------------
No significant bacterium 6000 CFU/ml

--------------------------------------------------------------------------------
Date(Time):1000908(1213), Stool cult
No Salmonella and Shigella spp isolated
--------------------------------------------------------------------------------
** 病毒學檢查 **
Date(Time) Rota virus
1000908(1213) Positive
--------------------------------------------------------------------------------
Date(Time):1000908(1213), 血液培養
No Growth after 5 days
(20)放射線
nil
報告
(21) 病理報
nil
告
(22)其他 nil
(23) 出院情
■改門診治療
況
(24)出院指
示
處----------置-----------名----------稱次劑量單位服法天總---量單位
Kascoal 40mg(加斯克兒錠) 1/ 4 粒 TIPO 4 3/ 1 粒
Antibiophilus(阿德比膠囊) 1/ 3 粒 TIPO 4 4/ 1 粒
Cefspan 100mg(Cefixime) 3/ 8 粒 BPPO 4 3/ 1 粒
糖粉 Sugar 1/ 1 次 TIPO 4 12/ 1 次
120ml Pecolin Susp(以瓶計價) 4/ 1 cc TIPO 4 1/ 1 瓶
78
出院病歷摘要 (婦產科)
0136010010 衛生福利部豐原醫院 ○○○ 00000000000 0年0月0日 oooooooo
(6)轉入醫院 (7)地址 00000000000 (8)流水編號
(9)入院日期 00 年 0 月 00 日婦產科 000000
(11)出院日期 00 年 0 月 0 日住院天數計 0 日
入 620.5 TORSION OF OVARY, OVARIAN PEDICLE OR FALLOPIAN TUB

(12) 院 789.00 ABDOMINAL PAIN
診
620.5 TORSION OF OVARY, OVARIAN PEDICLE OR FALLOPIAN TUB
斷出
789.00 ABDOMINAL PAIN
院
s/p laparoscope right salpingo-oophorectomy
(13)主訴 Low abdominal pain for one week.
Past History :
(14)病史 1.DM :denied
2.Hypertension :denied
3.Denied other systemic disease
4.Denied surgical history
Personal History & Allergic History :

1.NO habit of alcoholic drinking
2.No Smoking
3.No habit of betel nut chewing
4.No history of drug allergy
5.Occupation: Housewife
6.Ethnic origin:Taiwan
Family History :
Not contributory
Menstrual History:
Menarche at 13 Yrs.
Regularity: YES
Character & Amount:
Moderate amount
Dysmenorrhea( - )
Clots( - )
Marital State: Married
Present Illiness:
The 40 years-old married women, G3P2AA1, LMP: oo-oo-oo, was well-being
79
before.
According to the statement of the patient herself, she had regular
menses and no dysmenorrhea, she suffered from the continuous low abdominal
pain for one week. At first, she visited LMD for help and oral medication
was prescribed , but in vain. So she visited our ER for help and TVS
sonography showed right ovarian cystic tumor about 10cm, R/O torsion.
Therefore she admitted to our ward for surgical intervention.
Physical Examination :
(15)體檢發現 General appearance :a well-developed ,fair in stature ,female with acutely
ill-looking ,in no cardiopulmonary distress
Mental state: E4V5M6
Vital sign at ER :
BT:36.3 C BP :121/71 mmhg RR:20 /min PR:82 /min
Integument: normal skin turgor,no edema,no eruption ,no petechia,no
ecchymosis, no clubbing finger ,no cyanotic nail
HEENT: normal skull configuration and hair distribution no exophthalmos ,no
ptosis;sclera not icteric ,conjunctiva not pale isocoric pupils
,3mm/3mm in size ,with normal light reflex full EOM ,normal visual
acuity and color perception no discharge from ears ,no hearing
impairment no oral ulcer,normal palatal movement,tonsils not injected
Neck : supple ,with fair range of motion ,no carotid bruit ,no jugular vein
engorgement ,thyroid gland not enlarged ,no palpable lymph node or other
mass
Chest:
(1)Inspection :normal contour of ribs cage with symmetric expansion
(2)Palpation :normal tactile fremitus ,no subcutaneous emphysema
(3)Percussion :resonance ;no abnormal dullness
(4)Auscultation:clear BS with rales ,rhonchi or wheezing
Heart:
(1)Inspection:no visible PMI
(2)Palpation:no thrill,no heave
(3)Percussion:normal shape
(4)Auscultation:irregular/regular heart beat,no /grade II murmur
Abdomen:
(1)Inspection:flat shape ,no scar,nosuperficial vein engorgement
(2)Auscultation: normo-active bowel sound ,no gastric succussion
splash, no bruits
(4) Palpation:tenderness and rebouding pain over right underside palpable mass
over underside
(16) 手術日期 00/00/00 Under GA -> laparoscopic right side salpingo-oophorectomy

及方法(包括手 Operative and finding :
術發現) 1. Right ovary torsion with necrosis 10x8x7cm
2. Left ovary with normal appearence
3. Uterine myoma 2x2cm over post fundal region
4. Blood in cul-de-sac about 100ml
(17) 住院治療 00/00/00 Admitted via ER for pre-OP preparation

經過 00/00/00 Under GA, Laparoscopic R't salpingo-oophorectomy
00/00/00 The post -OP first day was stable
Flatus(+), try soft diet, wound CD
Change oral medication
00/00/00 Wound clear, MBD and OPD follow up next wednesday
80
Nil
(18)合併症
一般檢查(如:尿液.糞便.血液.生化.細菌......之檢查)
(19)檢查記錄 ** 尿液檢查 **
Date(Time) PH SP.gr protein Sugar urobilinog
000000(0900) 7.0 1.036 +(30MG) - 0.1
Bilirubin ketone Nitrite Occult WBC(定性)
+ +- - - -
RBC WBC Epithelial Bacteria Amorphous
0-1 3-5 3-5 + +
Date(Time) preg-EIA
0000000(0900) Negative
------------------------------------------------------------------------
Date(Time) * APTT * PT (sec * PT (INR)
000000(0900) 24.0 12.2 1.24
Date(Time) RBC WBC Hb Hct Platelet
000000(0900) 4.680 9.500 10.800 34.100 308.000
MCV MCH MCHC N-Seg Lymph
72.900 23.000 31.500 80.200 12.100
Mono Eosin Baso
7.200 0.100 0.400
---------------------------------------------------------------------------
Date(Time) Creatinine GOT Sugar-Ac
000000(0900) 1.200 20.000 130.000
----------------------------------------------------------------------------
特殊檢查(如:超音波.內視鏡.呼吸.循環.神經.泌尿.耳鼻喉.眼......之檢查)
TVS sonography showed: Right ovary cystic tumor 10cm
R/O torsion
Date(Time):000000(1940), Chest PA
(20) 放射線報
告 CXR
> The cardiac size and configuration are within normal range.
> Prominent pulmonary vascularity is noted.
> Some peribronchial thickening could be found.
> Increased infiltration in the bilateral low lungs was noted.
Date(Time):000000(1419), 第四級外科, 一般病理檢
(21)病理報告 Adnexa, right, salpingoophorectomy, benign ovarian serous cyst with torsion
(包括病理發 manifested as massive hemorrhagic infarction and adjacent foci of
現) endosalpingiosis in the paratubal soft tissue.
The specimen submitted consists of more than 10 tissue fragments measuring up

to 4 x 2.2 x 1.2 cm in size fixed in formalin.
Grossly, they are brown and soft.

Representative sections are taken and labeled as A1-A2. Jar 1
The microscopic findings are described in the diagnostic column. Neither
borderline epithelial change nor invasive malignancy is seen.
(22)其他 N-P
(23)出院情況 ■改門診治療
81
(24)出院指示處--------置-----------名----------稱次劑量單位服法天總---量單位
A.M.D 1/ 1 粒 TIPO 3 9/ 1 粒
Potarlon(Ponstan)250mg 1/ 1 粒 TIPO 3 9/ 1 粒
Encore gr. 200mg/3g 1/ 1 包 TIPO 3 9/ 1 包
WINCEF 500mg(UCEFA) 1/ 1 粒 BIPO 3 6/ 1 粒
Medicon-A Cap 1/ 1 粒 TIPC 3 9/ 1 粒
Colfon 1/ 1 粒 TIPC 3 9/ 1 粒
主治醫師蓋章:○○○ 住院醫師蓋章:○○○
出院病歷摘要（骨科）
82
衛生福利部豐
王○○ 00000000 00/00/00 000000*
0136010010 原醫院
(6)轉入醫院 (7)地址 000000000 (8)流水編號
(9)入院日期 100 年 09 月 08 日骨科病床號碼
(11)出院日期 100 年 09 月 12 日住院天數計 5 日
71531: Degenerative arthropathy, right knee
入
(12) 2500: Diabete Mellitus
院
診 4011: Hypertension
71531: Degenerative arthropathy, right knee
斷出
2500: Diabete Mellitus
院
4011: Hypertension
(13)主訴 Right knee pain with limping for 3 years
This 86-year-old woman has right knee pain and limping for about three
(14)病史 years. The symptoms are worse with standing and walking, exacerbate on stair
climbing, but relieved by rest and sitting. She can not walk over 2 block.
Varus deformed appearance on right knee are observed. At our OPD, radiographic
studies reveal advance tricompartment osteoarthritis on right knee joint. No
improvement noted after conservative treatment including medication and
rehabitation, she was admitted for further management.
PH: DM (+) for 20 years under OHA control
HTN ( +) for 10 years with good BP control at our CV OPD
Previous operation history:
Myoma, s/p hysterectomy 30years ago in XX hospital
(15)體檢發現【The Major Physical Examination Finding On Admission】
●General Appearance: nourished and developed.
●Integument: normal skin turgor, no edema, no eruption/rash, no petechia, no
ecchymosis,
●Mental state: Coma Scale：E(4)M(6)V(5)
●Consciousness：clear, not stupor, not coma
●Vital Signs：BP=125/78mmHg, PR=78/min, RR= 18 /min, BT= 36 ℃
●HEENT：
normal skull configuration and hair distribution without deformity.
◆Eyes：no exophthalmos, no ptosis, no abnormal deviation of eye-ball
normal visual acuity and color perception
conjunctiva：pale,no anemic.
◆Ear：intact and clear auditory cannel, no discharge from ears, no hearing
impairment.

◆Neck：supple, not stiff, with fair range of motion,
◆Tonque: no deformity,
◆Mouth: swelling of right side face, without skin erossion. Necrotic
protruding lesion over right buccal mucosa, invasion to mouth angle & chin.
◆Throat： not check
●Chest：sortness of breathing,
◆Palpation: obvious friction and near-floating of ribs over left side(between
anterior and middle axillary line), multiple, no subcutaneous emphysema
83
◆Percussion: not check due to severe tenderness
◆Auscultation: decreasing breathing sound over left lung, no rales,
no rhonchi, no coarse, no wheezing.
●Heart:
●Abdomen:
╰─╯ ◆Inspection: flat/distended shape,
╴ ∕Ｖ﹨＿ no scar, no superficial vein engorgement
∕ ＼／ ﹨ ◆Auscultation: normal-active bowel sound,
﹨ ⊙ ⊙∕ ◆Palpation: soft/guarded,
）︾ˇ︾（ Tenderness：NIL
∕ ﹨ Rebunding tenderness：NIL
∕ x ﹨ Liver/Spleen:non-palpable,
▏ ___ ▏ Palpable mass：NIL
●Back&spine:：normal curvature, no open wound, no scar,
no tenderness, no root pain, moderate flank knocking pain over left side
●Extremities and joints
Gait: antagia gait.
No muscular atrophy in bilateral lower limbs
Varus deform on right knee noted
No neurologic deficient
Right Left
ROM 15-90 5-120
Alignment Varus Neutra
l
Mechanical axis 18 degree varus 2degree varus
Anatomical axis 12 degree varus 5degree valgus
Ligament laxityM/L +/- -/ -
●Nervous system:
◆Mentality:fair orientation? attention.
◆Motor --MP: upper L 5/ R 5 lower L 5/ R 5
●Genital organ: intact, no herniation.
●Anus&Rectum: not performed
84
手術日期 20○○/○○/○○
(16)手術日期
麻醉方法: General Sugeon ＸＸＸassistant XXX, blood loss:300ml
及方法(包括
OP Methods:
手術發現)
Right total knee replacement, Zimmer, Nexgen , cemented ( Femur D, Tibia 3,
patella
26mm , insert 10mm ) OP findings:
1. hypertrophy synovial
2. Osteophyte formation
3. Osteoporosis
4. Subchrondrol cyst at the medial tibia plateau
5. Lateral release performed
(17)住院治療
After admission. This 86-year-old female received operation on 20○○/○○/○○.
經過
The patient tolerated the operation smoothly. After operation, her condition was
stable and the wound healed well. Right knee pain and limping were relieve after
operation. She can walk smoothly with walker ambulation now. Thus with stable
condition, she was discharge on 20○○/○/○.
(18)合併症 NIL
（19） ** 血液學檢查 **
檢 Date(Time) PT(INR) PT(sec") APTT
1000908(2118) 0.950 9.300 26.100
查
紀 10*0***(2118) 4.260 11.600 15.400 44.300 320.000
錄 36.200 34.900 103.900 71.700 19.100

0.400 1.300 7.500 14.300 15.500
MPV
7.500
) 13.000 9.800 0.850 144.000 3.800
S-GPT(ALT) e-GFR 腎絲 STAGE
33.000 98 STAGE 1
118.000
(20)放射線
20○○-○-○ Right knee ( AP+ Lat + Merchant ) X-ray
報告
Decrease on joint space compartible with advance osteoarthritis Osteophytes
formation note over the distal femur and proximal tibia Lateral tilting of
patella.
20○○-○○-○○: Chest X-ray: clear lung field, no active lung lesion
(21)病理報
病理報告 (pathological Report): osteoarthritis without inflammatory change
告
85
(22)其他 NIL
Regular wound care at home and keep dry

(23)出院情
況 Walk with walker support for 3 months
Qudriceps exercise and ROM training rehabititaion
OPD follow up 2 weeks later
Cataflam 1pc pot id x 14day for wound pain prn use
（24）出院
指示處----------置-----------名----------稱次劑量單位服法天總---量單位
Volna-K 25mg(待可服寧膜衣錠) 1/ 1 粒 TIPO 5 15/ 1 粒
A.M.Z(愛姆舒錠) 1/ 1 粒 TIPO 5 15/ 1 粒
出院病歷摘要（泌尿科）
86
(7)地址 00000000000 (8)流水編號
(6)轉入醫院
(9)入院日期 00 年 0 月 00 日泌尿科 000000
(12) 入
Acute epididymitis, left
診院
出
Left acute epididymitis with abscess s/p incision and drainage
斷院
(13)主訴 Painful swelling left scrotum for 3 days
This 38 years old man denied prior systemic disease before. He was in his
usual health status until 4 days before admission. Left painful swelling of
scrotum was reported.
Tracing back to his history, he denied ilegal sexal behavior with hooker
before and had only one sexal partner (his wife) only. The last intercourse
was
about 2 weeks ago and last self-ejaculation (with blood-tinged semen) was
about
one week ago. He started suffering from frequency, urgency, dysuria during
1-3 days after last ejaculation. Painful left scrotum was also reported. He
then
(14)病史
came to our URO OPD on 4/30 and recieved wincef treatment. Urine culture
collected at that time showed no growth. Pain subsided after antibiotic but
relapsed on 5/3. He came back to our OPD for medications. Fever with heavy
chills was noted after home. He then came to our ED for help.
Vital sign: 38.6'C, 100bpm, 156/102mmHg at arrival. PE showed left swelling
scrotum and lab showed leukocytosis (20000)with left shifting but not
significant increased CRP. Under the impression of acute epididymitis, he
then
was admitted to our ward for antibiotic treatment and surgical drainage if
abscess formation.
87
Consiousness: alert
(15)體檢發現 Vital sign:BP: 144/87 mmHg, PR: 100bpm, RR:18cpm, BT:38.5 ℃
HEENT: Conjuctiva: not pale; Sclera: anicteric
pupil: (3/3), light reflex: +/+
Neck: supple
lymphadenopathy (-), jugular vein engorgement (-)
Kernig sign (-), Brudzinski sign (-)
thyroid: impalpable
Chest: symmetric expansion, no accessory muscle usage
Breath sound: bilateral clear, no crackle
Heart sound: regular heart beat, no auditory murmur
Abdomen: soft, distention
Bowel sound: normo-active
Palpation: no abdominal tenderness
liver/spleen: impalpable, Muphy's sign (-), McBurney's sign (-)
Extremity:
Upper: no palmar erythema
Lower: ROM: full, no pitting edema
Skin: fair turgor, intact, no rash, no wound or bedsore
left scrotum: swelling, mild erythematous, severe tenderness
(16) 手術日期
101/05/07 78805C 副睪丸膿瘍切開引流
及方法(包括手
About 30ml pus within scrotum
術發現)
(17) 住院治療 After admission, fever off and on persisted after 3 days of cefazolin +
經過 gentamycin. We arranged incision and drainage on admission day 5 and shifted
antibiotic to cravit 750mg QD. Fever then subsided. Pain and swelling left
scrotum also got slow improvement. Lab data showed reduced WBC count and
CRP. The serous discharge from penrose also reduced. We then removed the
drain and kept close observation for wound condition. Now his condition is
stable and could discharge today. OPD follow up had been scheduled on 5/22.
(18)合併症 Nil
1010503(1603) 8.000 1.020 - - 1.000
- - - +/- 0-2
0-5 0-5 - +/-
-----------------------------------------------------------------------------
1010512(0858) 14.600 72.400 21.700 0.500 1.300
MONO
4.100

1010509(0804) 17.800 75.400 15.900 0.500 0.800
MONO
7.400
88
1010507(0757) 0.930 9.500 30.800

1010503(1603) 4.820 20.800 15.300 43.300 300.000
31.700 35.200 89.900 90.000 6.200
0.100 0.100 3.600 13.700 16.400
MPV
7.300
-----------------------------------------------------------------------------
---
1010512(0858) 5.300
1010509(0804) 13.200
Date(Time) BUN(Blood) Creatinine Na 鈉(boold K 鉀(Blood) S-GPT(ALT)

1010503(1603) 14.000 1.040 136.000 3.300 30.000
1.600 80 STAGE 2
1010503(1603) 130.000
-----------------------------------------------------------------------------
---
Date(Time):1010507(1006), Pus(from:O, Pus(from O
No aerobic bacteria was isolated

No anaerobic bacteria was isolated
-----------------------------------------------------------------------------
---
Date(Time):1010507(1006), Pus(from:O, Pus(from O
No aerobic bacteria was isolated
No anaerobic bacteria was isolated
-----------------------------------------------------------------------------
---
No growth
Scrotum echo: fluid accumulation over left scrotum
(20)放射線報
Pending
告
89
(21)病理報告 Scrotum, left, incision and drainage ---- Fibrinopurulent exudate.
( 包括病理發 Testis, left, needle biopsy ---- Coagulative necrosis.
現) ---------------------------------------------------------------------------
The specimens are submitted in 2 bottles, and labelled as 1) left scrotum,
and 2) left testis, fixed in formalin.
Bottle 1, labelled "left scrotum", consists of 9 tissue fragments measuring
up to 2.8 x 1 x 0.3 cm in size. Grossly, they are tan-white to tan and
elastic.
Bottle 2, labelled "left testis", consists of 4 tissue fragments measuring
up to 2.2 x 0.1 x 0.1 cm in size. Grossly, they are tan-white and elastic.
All for section and labelled as follows:
A: left scrotum
B: left testis Jar: 0
Microscopically, section A from left scrotum shows pieces of fibrinopurulent
exudate, suggestive of localized abscess. No necrotic soft tissue is
included.
Section B from left testis shows marked coagulative necrosis of
seminiferous tubules.
(22)其他 Nil
(23)出院情況 ■改泌尿科門診治療
(24)出院指示
處----------置-----------名----------稱次劑量單位服法天總---量單位
Cravit 500mg(可樂必妥膜衣錠) 3/ 2 粒 MAPO 7 21/ 2 粒
Purfen 400mg(普服芬膜衣錠) 1/ 1 粒 TIPO 7 21/ 1 粒
主治醫師蓋章:○○○ 住院醫師蓋章: ○○○
90
出院病歷摘要 (復健科)

(6)轉入醫院 (7)地址 00000000000 (8)流水編號
(9)入院日期 00 年 0 月 00 日復健科 000000
1.Traumatic brain injury with right hemiplegia
入
(12) 2.Hydrocephalus s/p ventricle-peritoneal shunt
院
診 3.Hypertension
1.Traumatic brain injury with right hemiplegia
出
斷 2.Hydrocephalus s/p ventricle-peritoneal shunt
院
3.Hypertension
(13)主訴 Admission for rehabilitation due to right limbs weakness since 100/10/07.
Body length: bed-ridden
(14)病史 Body weight: bed-ridden
Marital status: 離婚
Place of residence: 彰化市
Past history: hypertension
Allergic history: denied
Present Illness:
This 45 y/o male patient has the past history of hypertension. Under his
family's statement, he suffered from traffic accident when riding
motorcycle. And then he was sent to 彰化基督教醫院 ER for help where
GCS:E4M6V1. Brain CT showed subdural hematoma over left
frontotemporoparietal region with mass effect and uncal herniation. Due to
that, craniectomy was done on the same day. On 100/02/07, hydrocephalus was
noted. Due to that, V-P shunt insertion and cranioplasty was done. After
his clinical sondition improved, PM&R was arranged. And then PM&R programs
were arranged in 彰基 and 秀傳 H. Due to impaired functional status and
ADL performance with right hemiplegia, and impaired cognition, he was
admitted to our ward for further rehabilitation.
Personal History
1.Alcoholic drinking: quit since this episode
2.Smoking: quit since this episode
3.Betel nut chewing: nil
Family History
Nil
Review of systems
1.General: no fever, no anorexia, no insomnia, no agitation
2.Integument: no skin hyperpigmentation, no jaundice, no cyanosis, no
pruritus,
no skin rash
3.HEENT: (1)Head: no headache, no dizziness, no vertigo
(2)Eyes: no pain, no blurred vision, no diplopia, no photophobia
(3)Ears: no pain, no discharge, no tinnitus
91
(4)Nose: no epistaxis, no congestion
(5)Mouth and throat: no bleeding gum, no oral ulcer, no
soreness,
no hoarseness, no throat pain
(6)Neck: no pain, no stiffness
4.Respiratory: no cough, no sputum, no hemoptysis, no wheezing
5.Cardiovascular: no dyspnea on exertion, no paroxysmal nocturnal dyspnea,
no orthopnea, no palpitation
6.Gastrointestinal: no nausea, no vomiting, no abdominal pain,
no change of bowel habit, no hematemesis,
no bloody or tarry stool
7.Genitourinary: no frequency, no urgency, no dribbling, no incontinence
no dysuria, no hematuria, no nocturia, no polyuria
8.Metabolic: no growth retardation, no body weight loss, no heat or cold
intolerance, no polydipsia
9.Hematologic: no easy bleeding, no lymphadenopathy
10.Neuropsychiatry: no syncope, no seizure, no anxiety, no depression
(15)體檢發現 1.General appearance: moderate developed, in no distress
2.Consciousness: clear
4.Integument: normal skin turgor, no petachiae, no ecchymosis
5.HEENT:Head: no fracture, no open wound
Eye: no pale conjunctiva, no icteric sclera
no ptosis, no blurred vision
Ear: no deformity, no discharge
Neck: supple, no LAP, no JVE
Throat: no throat pain, no throat congestion
6.Respiratory: symmetrical expansion,
barrel chest wall noted
bilateral clear breathing sounds
7.Cardiovascular: regular heart beat, no murmur
8.Gastrointestinal: flat, soft, no tenderness, no superficial vein
engorgement,
normactive bowel sound, normal liver span
9.Genitourinary: no flank knocking pain, no hematuria, no urine frequency, no
urgency, no nocturia, no dysuria
10.Metabolic: no thyroid enlargement, no pitting edema, no hand tremor
11.Musculoskeletal:no bone pain, no arthralgia, no muscleache, no deformity
12.Hematologic: no petechia, no ecchymosis
<Neurological Examinations>
1.Consciousness: clear with RLA level:6-7
2.JOMAC: impaired to calculatuion and memory
3.Speech: fluent, no dysarthria,
comprehension: can follow verbal order or gesture,
expression: intact
repetition: intact,
spontaneous verbal output: intact
naming: intact
5.Cranial Nerves
CN II: Visual acuity & Visual field: grossly intact
Pupils: isocoric; Light reflex: +/+
CN III-IV-VI: EOM: free and full; No ptosis
CN V: Facial sensation: symmetric and intact
Mastication:grossly intact; Corneal reflex R/L:+/+
CN VII: Left central facial palsy
92
CN VIII: No obvious hearing impairment; No nystagmus
CN IX,X: Velar elevation: symmetric; Gag reflex: +/+
CN XI: SCM/Trapezius: grossly intact
CN XII: no Tongue deviation
6.Motor: Brunnstrom's stage- RUE proximal/distal: Brun. stage II/II-III
RLE: Brun. stage II-III
7.Deep Tendon Reflex: increased over right side
8.Spasticity: MAS 2 over right limbs
9.Sensation: can not test
10.Coordination: Finger to Nose test: no obvious dysmetria
11.Sphincter: continent
<Functional status> Rolling to R/L: I/D

Sitting balance S/D: F-G/F
Standing up: moderate assistance
<Functional Independence Measure, FIM>

(1)Self care
A. Eating 6
B. Grooming 2
C. Bathing 2
D. Dressing
upper body/lower body 3/2
E. Toileting 2
(2)Sphincter control
G. Bladder management 4
H. Bowel 3
(3)Transfer
I. Bed, chair, wheelchair 3
J. Toilet 2
K. Tub,shower 2
(4)Locomotion
L. Walk/wheelchair 3
M. Stairs 1
-------------------------------------------Motor subtotal score:35/91
(5)Communication
N. Comprehension 6
O. Expression 5
(6)Social cognition
P. Social interaction 5
Q. Problem solving 3
R. Memory 4
-------------------------------------------Cognitive subtotal score:23/35
Total FIM: 58/126
(16) 手術日期 Nil.
及方法(包括手
術發現)
93
After admission, rehabilitation including physical, occupational,
(17) 住院治療 and speech
經過 therapy was arranged for the patient.
Physical therapy:
Facilitation technique, ambulation training, PROM exercise, strengthen
training,
endurance training.
Occupational therapy:
Posture training, PROM, balance training, moving training, ADL training,
functional training
On 101/04/18, due to poor and slow response, brain CT was followed to rule
out hydrocephalus. Brain CT showed no new onset leision or hydrocpehalus.
Since admission, unsteady gait and poor trunk control were noted. After
training, fair activation of learning and exercise was noted. Due to that,
there was limited improvement was noted during this hosiptal course.
Dehydration was noted due to poor intact from oral, and then IV hydration
was performed. After IV hydration, his clinical response and activation
were improved.
Now his clinical status:
1.Consciousness: clear with RLA level:6-7
2.JOMAC: impaired to calculatuion and memory
3.Speech: fluent but slow response
5.Motor: Brunnstrom's stage- RUE proximal/distal: Brun. stage II/II-III
RLE: Brun. stage II-III
6.Spasticity: MAS 2 over right limbs
<Functional status> Rolling to R/L: I/D

Sitting balance S/D: F-G/F
Standing up: moderate assistance
The patient is discharged under stable condition.
Further rehabilitation is suggested.
(18)合併症 Nil
1010430(1704) 7.000 1.015 - - 0.100
- - - - 0-2
WBC Epithelial Bacteria WBC(定性) Salt(1)
0-5 0-5 1+ +/- Amor. Phos
1010424(1550) 7.000 1.015 100 mg/ - 0.100
94
- - - +/- 0-2
0-5 0-5 +/- -
1010412(1654) 6.500 1.018 +/- - 0.100
- - - +/- 0-2
30-50 0-5 2+ 2+
-----------------------------------------------------------------------------
---
** 糞便檢查 **
Date(Time) OB
1010420(0855) +/-
Date(Time) OB Consistenc Color Mucus PUS
1010412(1654) 3+ Formed Brown - -
Blood RBC WBC Parasite
- - - Not found
-----------------------------------------------------------------------------
---
Date(Time) W.B.C 白血 Hemoglobin N-Seg Lymph Baso
1010516(1135) 5.200 15.900 47.500 39.300 0.300
Eosin MONO
5.900 7.000
Date(Time) W.B.C 白血 Hemoglobin N-Seg Lymph Baso
1010509(1046) 6.000 17.100 55.000 39.500 0.500
Eosin MONO
3.600 1.400
1010413(1654) 4.810 6.100 14.300 42.100 307.000
29.800 34.000 87.500 51.400 39.800
0.600 3.600 4.600 14.300 16.000
MPV
7.400
-----------------------------------------------------------------------------
---
Date(Time) BUN(Blood) Creatinine e-GFR 腎絲 STAGE
1010516(1135) 8.000 0.660 130 STAGE 1
Date(Time) BUN(Blood) Creatinine Na 鈉(boold K 鉀(Blood) e-GFR 腎絲

1010509(1046) 22.000 1.220 134.000 4.700 64
STAGE
STAGE 2
1010413(1654) 9.000 78.000 0.810 134.000 4.200
S-GOT(AST) S-GPT(ALT) e-GFR 腎絲 STAGE
15.000 13.000 103 STAGE 1
(20)放射線報 Date(Time):1010507(0843), Chest PA, K.U.B.
告
KUB showed:
> Stool retension in the large bowels.
95
> Degenerative change of the L spine
with spur formation.
> S/P V-P shunt insertion.
Please correlate with clinical
condition and follow up if clinically
needed
Chest PA view was performed, which

showed:
> Calcified aorta with normal heart size.
> Increased lung marking.
> Mild increased bronchial wall thickening at the bilateral lower lung fields
was found, R/O bronchiolitis. Please correlate with clinical condition and
follow up if clinically needed.
> Suspicious a faint nodule at the right upper lung field was found, nature
to be determined. Suggest follow up.
> S/P V-P shunt insertion.
Please correlate with clinical
condition and follow up if clinically
needed
(21)病理報告 Nil.
(包括病理發
現)
(22)其他 Nil.
(23)出院情況 ■改門診治療
(24)出院指示處----------置-----------名----------稱次劑量單位服法天總---量單

位
Takepron OD 30mg(泰克胃通口溶錠) 1/ 1 粒 MAPO 1 1/ 1 粒
Hamgo gr.for oral sol'n 1200mg 1/ 1 包 TIPO 1 3/ 1 包
Befon 10mg(倍鬆錠) 1/ 1 粒 BPPO 1 2/ 1 粒
Zolnox 10mg(樂必眠膜衣錠) 1/ 1 粒 HSPO 1 1/ 1 粒
Through 20mg(便通樂膜衣錠) 2/ 1 粒 HSPO 1 2/ 1 粒
Amizide (安立壓錠) 1/ 1 粒 MPPO 1 1/ 1 粒
Mesyrel 50mg(美舒鬱錠) 1/ 1 粒 TIPO 1 3/ 1 粒
主治醫師蓋章:○○○ 住院醫師蓋章: ○○○
96
出院病歷摘要 (耳鼻喉科)

(6)轉入醫院 (7)地址 00000000000 (8)流水編號
(9)入院日期 00 年 0 月 00 日婦產科 000000
入 780.53 Obstructive sleep apnea (OSA)

(12) 院 474.00 chronic tonsillitis
診
780.53 Obstructive sleep apnea (OSA)
斷出
474.00 chronic tonsillitis
院
s/p UPPP (uvulopalatopharyngoplsty) on 101-00-00.
(13)主訴 snoring noted for 4 years.
(14)病史 ■ 現況病史
This 55 year-old male with the past history of hypertension with
medication was
admitted via OPD due to snoring for 4 years. According to the statement of
the patient
himself, he suffered from snoring for a long time and the condition of
snoring got
worse in recent 4 years . He also complained of hypersomnolence and dry
97
throat in the
morning. He went to our hospital for help. At our ENT OPD, enlarged
tonsils (Gr
II-III) and redundant soft palate were found on physical exam.Cephalometry
and
nasopharyngoscopy showed narrowed retro-palatal space. Polysomnography was
performed and showed apnea-hypopnea index (AHI) 96/hr. Under the impression
of 1)
bstructive sleep apnea and 2) chronic tonsillitis, he was admitted for
further evaluation
and surgical treatment.
Throughout the whole course, there were snoring, hypersomnolence and
dry
throat. There was no frequent sore throat, purulent rhinorrhea, sneezing, or
stridor.
■ 既往病史
1. DM: denied
2. Hypertension: with medication.
3. Other systemic disease: denied
4. Surgical history: septomeatoplasty on 98-06-10.
5. Hospitalization: once (due to septomeatoplasty)
■ 社會史
2. No Smoking
5. Occupation : business
■ 過敏史
■ 家族史
■ 系統回顧
1. Systemic: No fever, BW loss, easy-fatigibility, change of appetit or
dizzines
2. Skin: No petechiae, purpura, skin rash, or itching.
3. HEENT: ** snoring, hypersomnolence and dry throat**
No nasal obstruction, rhinorrhea, blurred vision , strabismus,
ocular
pain, ear ache, hearing impairment, otalgia, otorrhea, tinnitus,
vertigo, nasal pain, gum bleeding, sore throat, odynophagia,
epistaxis,
husky voice, oral pain or ulcer.
4. Cardiovascular: No exertional chest tightness, PND, orthopnea,
syncope,
palpitation, or intermittent claudication.
5. Respiratory: No dyspnea , cough, sputum, chest pain or hemoptysis.
6. GI: No anorexia, nausea, vomiting, dysphagia, heart burn, acid
regurgitation,
abdominal fullness, midnight pain, constipation, diarrhea, melena,
98
change
of bowel habit, tenesmus , or flatulence.
7. Urogenital: No flank pain, hematuria, urinary frequency, urgency,
dysuria,
hesitancy, oliguria, small stream of urine, impotence, nocturia
o
polyuria.
8. Musculoskeletal: No bone pain, arthralgia, muscleache, or weakness.
9. Metabolic: No heat intolerance, cold intolerance, or thirsty.
10. Nervous: No numbness or paresis.
(15)體檢發現 ■ 理學檢查
Conscious: Clear
GCS: E4V5M6
Vital Signs: BP: 128 / 77 mmHg TPR: 36.0 ℃, 72 /min, 20 /min
INTEGUMENT: Normal skin turgor, No edema, eruption, petechiae, ecchymosis
or clubbing finger
HEENT: Conjunctiva: not pale
Sclera:Not icteric
No ptosis
Iscoric pupils with normal light reflex
Normal visual acuity
Ear: bil eardrum: intact
Nose: patent nasal cavity.
Oral cavity: smooth mucosa.
Tonsils: wound s/p uvulopalatopharyngoplasty (UPPP) was well
healing,
just minimal bloody discharge and some crust coating.
Pain score: 2-4 degrees.
Neck: Supple, no lympadenopathy , no JVE,
Thyroid gland: not enlarged
Larynx: no polyps or nodule, freely movable
CHEST: Bilateral symmetric expansion
Breath Sound: Clear
Percussion: Resonance
HEART: Regular heart beat, no murmur
ABDOMINEN: Flat, no scar, superficial vein engorgement
Active bowel sound, no bruits
Soft, no tenderness,
Normal liver and spleen span
EXTREMITIES: No edema or deformity; freely movable
EKG: Sinus rhythum
CXR: symmetric lung expansion
(16) 手術日期
0000/00/00 Under GA , UPPP (uvulopalatopharyngoplasty)
及方法(包括手
Operative finding :
術發現)
1. enlarged tonsils (Grade II-III)
2. redundant soft palate
99
(17) 住院治療
經過
The patient was admitted and treated with:
1.Set up for uvulopalatopharyngoplasty (UPPP)
2.Check CBC/DC, SMA, EKG, CXR
3.IVF supply
4.Antibiotic therapy: stazolin 1gm Q8H IVD x 3 day
5.Analgesic agents therapy: Volna-K 25mg QIDPC PO & tencam 20mg Q6H prn if
severe pain
6.Plaslloid 1gm Q8H IVD x 3 days
7.prednisolone 5mg BIDPC PO
8.Systemic care
9.Explain and education
There was no stress after treatment, then arrange discharge.
(18)合併症 Nil
(19)檢查記錄 ** 血液學檢查 **
1010429(1045) 1.010 10.100 26.000
-------------------------------------------------------------------------
------------------------
1010429(1045) 4.060 6.400 13.000 37.500 215.000
MCH MCHC MCV RDW PDW MPV
32.000 34.800 92.100 12.600 15.900 8.300
-------------------------------------------------------------------------
---------------------------
Date(Time) BUN(Blood) Glucose(AC) Creatinine Na 鈉(boold) K 鉀(Blood)
1010429(1045) 15.000 120.000 0.800 141.000 3.800
105.000 20.000 20.000 76 STAGE 2
----------------------------------------------------------------------------
特殊檢查(如:超音波.內視鏡.呼吸.循環.神經.泌尿.耳鼻喉.眼......之檢查)
Nil
(20)放射線報 Date(Time):000000(1940), Chest PA, CXR

告 > The cardiac size and configuration are within normal range.
> Prominent pulmonary vascularity is noted.
> Some peribronchial thickening could be found.
> Increased infiltration in the bilateral low lungs was noted.
100
(21)病理報告 Specimen 1:Tonsil, bilateral? UPPP ----- Reactive lymphoid
( 包括病理發 hyperplasia.
現) Specimen 2:Uvula, UPPP ----- Edema.
Specimen 3:Pillar, UPPP ----- Edema.
Received in formalin are 3 specimens.
Specimen 1 are 2 pieces of tonsillar tissue (3.5x2.3x1.5 cm and 3.2x2x1.3cm).
Specimen 2 is 2 pieces of gray tan soft tissue (largest 2x1x0.4 cm).
Specimen 3 is 3 pieces of gray tan soft tissue (largest 1.2x0.5x0.3 cm).
Representative part of the tissue of specimen 1 is taken for section.
All of the tissue of specimen 2 and 3 is submitted for section.
Totally cassette A to D are submitted.
Cassette A,B: Specimen 1, tonsil.
Cassette C: Specimen 2, uvula.
Cassette D: Specimen 3, pillar.
Microscopic examination is performed.

Microscopic description is not provided.
(22)其他 Nil
(23)出院情況術後傷口癒合良好,故予辦理出院並預約 0000-00-00 下午耳鼻喉科回診治療.
(24)出院指示
處置名稱單次劑量/單位服法天數總量/單位
Flamquit 50mg 1 / 粒 QIPO 3 12 / 粒
Musco 30mg 1 / 粒 QIPO 3 12 / 粒
Winlex 500mg 1 / 粒 BIPO 3 6 / 粒
Transamin 1 / 粒 QIPO 3 12 / 粒
1.請病患依醫囑按時服用藥物及確實配合回診治療
2.術後一週內建議避免搬運重物或劇烈運動(如:登山或騎腳踏車等)
3.傷口完全復原約需 2-3 週,飲食建議避免過熱或進補食物(人蔘當歸等)
主治醫師蓋章：○○○ 住院醫師蓋章：
手術記錄（外科）
101
姓性別：男年齡：00 歲　0000-00 病歷號碼：000000
名：○ ○ ○
日期及時間：101 年 00 月 00 日 00 時 00 分至 00 時 00 分
術者：○ ○ ○ 助手：○ ○ ○
麻醉：General anesthesia
手術前：Cancer of descending colon with total obstruction
診
斷手術後：Cancer of descending colon with total obstruction
手術術 Subtotal colectomy with ileorectal anastomosis

式：
手術發現：
1. An ulcerative tumor about 2x3x4 cm over descending and sigmoid colon
junction annular type
with total obstruction, direct invasion to serosa layer and multiple seeding
over pericolic
mesocolon.
2. Severe dilatation of proximal colon and small intestine, minimal ascites.
3. Distal cut margin about 10cm.
4. No palpable mass over liver.
手術過程：
1. Patient was put in modified trendelenburng’s lithotomy position after GA.
2. Skin was prepared and drapped as usual.
3. Mid Exp Lapa was done from 10 cm above umbilicus to pubic area 10 belowed
102
umbilicus.
Deepened to linea alba ,and opened thelinea alba and entered
into peritoneal fat ,open
peritoneum entered into peritoneal cavity.
4. OP finding was described as above.
5. First, separated the told’s white line Mobilized the mesosigmoid,
identified the inferior
mesenteric artery and transeced it with doubled ligation, the inferior
mesenteric vein was
treated with the same methods. Protected the left ureter.
6. The paragutter line of descending colon was separated and splenic flexure
was took
down, separated the gastrocolic ligament and hepatocolic ligament.Then, the
ascendimg colon
was mobilized and cecum was also dissected free . then, ileocecal vessels
and Middle colic, R’t
colic vessels all were transected with double ligation.
7. Then. Separated the mesocolon from descending colon to ascending colon and
mesentery of
terminal ileum. Transected the terminal ileum over 5 cm from ileocecal
valves, distal
transaction was over 10 cm distal to tumor.
8. The whole specimen was removed smoothly, Then, end to end anastomosis with
two layers by
hand sewn was done smoothly/ Check bleeding and a 13 mm Jenson-plate drain
was placed in
pelvic cavity.
9. Abdominal wound was closed in two layers total blood loss about 150cc,
Patient stood well
while sent to POR.
手術記錄（婦產科）
姓名：黃○○ 性別:女 Age:31 歲床號:1303-01 病歷號碼:4○1○5○

日期及時間: 101 年 04 月 16 日 13 時 30 分至 14 時 20 分
術者: ○○○ 助手:○○○
麻醉: General anesthesia
103
手術前:right side tubal pregnancy
診
斷
手術後：right side tubal pregnancy
手術術式: Laparoscopic— right salpingectomy
手術發現：
1.Uterus：normal size
2.Adnexal：right tube pregnancy
3.CDS：blood accumulation
4.Blood loss：400 ml
Op wound left right

手術過程：
1. The patient was on ■supine□lithotomy position, sterile preparing
& drapping of abdominal skin was done.
2. After anesthesia was effective , made a small transverse incision
below the
umbilicus and insert the Vere’s needle , after checking for safety,
CO2 was
pumping into peritoneum till the intrabdominal pressure reached
15mmHg.
3. Insert the trocar and video laparoscope, viewing whole pelvic organ.
4 Checked bleeding, then closed the wound.
5 Patient stood the whole procedure well.
Record by：○○○
手術記錄（骨科）
姓名：OOO 性別:男年齡：00 歲第 0000-0 床病歷號碼: 000000
日期及時間: 年月日時分上/下午至時分上/下午
術者: OOO 助手: OOO
麻醉:SA
診手術前: 1) osteoarthritis， Right knee
104
手術後: 1) osteoarthritis ，Right knee
斷
手術術式: total knee replacement Right
手術發現： Right knee ： adranced osteoarthritis -> joint space

narrowing, subchodral sclersosis /cyst, cartilage destruction, marginal
osteophytes formation, with varus deformity; 2 compartment involvement
was noted (medial and patello-femoral joint)
手術過程：
1. P't on supine position under spinal anesthesia
2.Aseptic manner and drape the right lower limb
3.Midline skin incision of medial parapatellar approach
4.Series bony cutting with jig A/B/C, and fix the prosthesis by
cement
5.Irrigate and check bleeding
6.Set hemo-vac drainage
7.Close wound in layers and dress it
8.Send patient to POR
Record By:○○○
手術記錄（泌尿科）
姓名：王○○ 性別：男年齡： 38 病歷號碼：

00000
日期及時間： 101 年○○月○○日 9 時 25 分至 10 時 00 分
術者：李昇平
麻醉：mask general anesthesia(patient refused spinal
anesthesia)
105
手術前診斷：Right epididymitis with abscess formation
手術後診斷：Right epididymitis with abscess formation

手術術式： Incision and Drainage
OP finding： 1. About 30ml pus within tunica vaginalis

2. generalized swelling of left testis, biopsy x
1
3. Left epididymal head swelling
4. some necrotic tissue removed, sent to patho
6# Penrose drain inserted
OP procedure：1.mask general anesthesia(patient refused spinal

anesthesia), lithotomy position
2.disinfected and drapped
3.left scrotal transfer incision 5 cm
4.Dissect the layers to tunica vaginalis
5.open tunia vaginalis, drain the pus
6. removal necrotic tissue, sent to patho
7. irrigate the wound with 2000 normal saline
8. A 6# Penrose drain insertion(after testis
biopsy done)
9.Closure the wound with 2-O catgut & compression
dressing
Record By:
106
手術記錄（耳鼻喉科）
姓名：OOO 性別:男年齡：00 歲第 0000-0 床病歷號碼: 000000
日期及時間: 年月日時分上/下午至時分上/下午
術者: OOO 助手: OOO
麻醉:GA
診手術前: 1) obstructive aleep apnea 2) chronic tonsillitis
斷手術後: 1) obstructive aleep apnea 2) chronic tonsillitis
手術術式：Uvulopalatopharyngoplasty (UPPP)
手術發現：（1）enlarged tonsils (gradeII-III)
（2）redundant soft palate

手術過程：
1.Under GA, the patient was placed into supine position with neck
hyperextended, the oral carvity and nasal cavuty were sterilized first.
2.The incision line was made over the ant pillar then dissection was made
till
the upper pole of tonsil was exposed,then the tonsil was dissected between
the capsule of tonsil and muscular layer of pharynx till the lower pole of
tonsil was exposed.
3.The tonsil was removed with tonsil clump, the bleeders were checked.
4.The same procedure was performed on the other side.
5.The prolonged uvula was shortened with preserved the muscular layer, then
the ant. and post pillar were sutured tog-ether with the depth of
oropharynx
about 1.5cm.
6.The whole procedure was smooth.
7. The blood loss was minimal.
8.The patient was sent to POR with a stable condition.
Record By:
107
CV cardiovascular
CVP central venous pressure
四、本院常見英文縮寫 CXR chest X-ray
不適用於出入院診斷、手術前 D&C dilatation and curettage
後診斷、手術式 D5W 5% dextrose in water
縮寫全名 DC discontinue
aa of each disseminated intravascular
DIC
Ac ante cibum(before meals) coagulation
Af atrial fibrillation Ditto the same
AFB acid fast bacillus DJD degenerative joint disease
AGN acute glomerulonephritis DM diabetes mellitus
acquired immune deficiency DNR do not resuscitate
AIDS
syndrome DOA dead on arrival
AM morning DOE dyspnea on exertion
amp ampule DPT diphtheria-pertussis-tetanus
AP anteroposterior Dr doctor
acute respiratory distress DVT deep venous thrombosis
ARDS
syndrome Dx diagnosis
ASD atrial-septal defect e.g. for example
ASHD arteriosclerotic heart disease enzyme-linked immunosorbent
ELISA
ATN acute tubular necrosis assay
BBB bundle branch block EMG electromyography,electromyogram
BP blood pressure ENT ear-nose-throat
BPH benign prostatic hypertrophy ER emergency room
BSO bilateral salpingo-oophorectomy ESRD end-stage renal disease
Bx biopsy et and
C/S caesarean section F/U follow-up
C/T chemotherapy FHx family history
Ca carinoma or cancer FSH follicle-stimulating hormone
CAD coronary artery disease FTSG full-thickness skin graft
Cath catheter FUO fever of undetermined origin
CBC complete blood count Fx fracture
CC chief complaint G gravida,gravid
CGN chronic glomerulonephritis 　 (number of pregnancies)
CHD congenital heart disease 　 (產科使用)
CHF congestive heart failure GI gastrointestinal
CMV cytomegalovirus Glu glucose
CNS central nervous system gtt(s) drops(Latin:gattae)
CO2 carbon dioxide GU urology
chronic obstructive pulmonary GU genitourinary
COPD
disease GYN gynecology
CPC clinicopathological conference H/D hemodialysis
CPR cardiopulmonary resuscitation HEENT head-eyes-ears-nose-throat
CSF cerebrospinal fluid HLA human leukocyte antigen
CT CAT scan HSV herpes simplex virus
108
NG tube nasogastric tube
history
Hx non-insulin dependent diabetes
NIDDM
I&D incision and drainage mellitus
I&O input and output nothing per os(nothing by
NPO
i.e. that is mouth)
ICH intracranial hemorrhage nonsteroidal anti-inflammatory
NSAID
drugs
ICP intracranial pressure
NSR normal sinus rhythm
ICU intensive care unit
OBS-GYN obstetrics and gynecology
insulin-dependent diabetes
IDDM OD right eye
mellitus
im 或 IM intramuscular OP operation
IP interphalangeal joint OPD outpatient department
IQ intelligence quotient Ophth ophthalmology
HLA human leukocyte antigen OR operating room
HSV herpes simplex virus open reduction/internal
ORIF
fixation
idiopathic thrombocytopenic
ITP OS left eye(oculus sinister)
purpura
IUD intrauterine device OU both eyes
IVP(IVU) intravenous pyelogram Oz ounce
iv 或 IV intravenous number of living children
Para
(產科使用)
kcals kilocalories
Patho Pathology
KUB kidneys,ureters,bladder
pc post cibum(after meals)
Lab laboratory
PDA patent ductus arteriosus
LAO left anterior oblique
PE physical examination
LAT lateral
PID pelvic inflammatory disease
liq liquid
pm,PM afternoon
LLL left lower lobe
PND paroxysmal nocturnal dyspnea
LLQ left lower quadrant
po by mouth
LMD local medical doctor
post-op after operation
LMP last menstrual period
purified protein
LOC loss of consciousness PPD
derivative(tuberculin)
Lt left pre-op before operation
LUL left upper lobe prn as needed(pro re nata)
LUQ left upper quadrant p't patient
LV left ventricle PU peptic ulcer disease
LVH left ventricular hypertrophy q1h every hour
Lymph lymphocyte q2h,q3h every 2 hours,every 3 hours
mcg(μg) microgram q-am every morning
MD medical doctor R/O rule out
ml milliliter(syn.cc) RA rheumatoid arthritis
mm 1 millimeter RAD radiation-absorbed dose
MRI magnetic resonance imaging REM rapid eye movement
NEG or RF rheumatoid factor
negative
neg
Rh Neg rhesus factor negative
NEURO neurology
Rh Pos rhesus factor positive
109
rheumatic heart wks weeks
RHD disease WNL within normal limits
RLL right lower lobe Wt weight
RLQ right lower quadrant
RML right middle lobe
RN registered nurse
Rt right
RUL right upper lobe
RUQ right upper quadrant
Rx treatment,therapy
S/P status post
SaO2 hemoglobin oxygen saturation
SBE subacute bacterial endocarditis
sc subcutaneous
SDH subdural hematoma
syndrome of inappropriate
SIADH
antidiuretic hormone
SICU surgical intensive care unit
SLE systemic lupus erythematosus
SOB shortness of breath
Staph Staphylococcus
at once, immediately and
Stat
once only(Latin: statim)
Strep Streptococcus
STSG split-thickness skin graft
Surg surgery or surgical
Tab tablet
TAH total abdominal hysterectomy
TB tuberculosis
TIA transient ischemic attack
TMJ temporomandibular joint
TPN total parenteral nutrition
TPR tempertaure, pulse, respiration
transurethral resection of the
TURP
prostate
U unit
U/A urinalysis
UGI upper gastrointesinal
URI upper respiratory infection
UTI urinaly tract infection
UV ultraviolet
premature ventricular
VPC
contraction
VSD ventricular septal defect
WBC white blood count
110
肆、衛生福利部豐原醫院病歷管理規章
一、衛生福利部豐原醫院病歷資訊管理會設置要點
第一條：本院為建立完整之病歷資料，提供醫療資訊，擴大服務病患加強病歷管理，於 80 年 3 月
特設置病歷管理委員會(以下簡稱本會)。
第二條：本會之任務如下：
一、設定疾病分類系統及審核病歷表格和內容的標準化和統一化。
二、定期實施病歷稽核，俾謀改進病歷記載之正確性及標準化。
三、監督醫師書寫病歷之內容。
四、討論有關病歷之問題和程序。
五、有關病歷室工作之協助推進事項。
第三條：本會設置委員十一至二十三人，由院長就有關人員中指派兼任，並以副院長為召集人。
第四條：本會委員任期為二年，連派得連任。
第五條：本會每三個月召開會議乙次，主任委員或兩名以上委員要求時，可召集臨時會議，會議
之召集，由主任委員負責。
第六條：本院開會除請院長出席指導外，並得通知有關人員列席以備諮詢。
第七條：本會需有過半數委員之出席而正式開會，出席委員過半數之同意方得決議，本會會議有
關報告事項及討論事項應作成記錄簽報院長核定後交有關科室執行。
第八條：本會置幹事一人由院長指派兼任，受主任委員之監督指揮辦理有關會議記錄及文書等事
項。
第九條：本規則提經院務會議通過後實施，修改時亦同。
病歷管理委員會名單
職務名稱姓名現職備註
召集人匡勝捷副院長
副召集人林振崧副院長
副召集人劉益坊內科主任
委員兼執行秘書方心怡病歷室主任
委員林美玲政風室主任
委員黃建文內科系醫療秘書
委員陳喜文外科系醫療秘書
委員林秀櫻外科系醫療秘書
委員吳淑娟復健科主任
委員蔡儀勳骨科主任
委員張崑敏病房主任
委員林正修病房主任
委員賴基鴻病房主任
委員江俊士病房主任
委員胡宗慶免疫風濕科主任
委員林仕穎泌尿科主任
委員蔡佑杰安寧病房主任
委員林雍凱心臟外科主任
委員王敏雄心臟內科醫師
委員劉彩娥督導
委員柯宗良資訊室組長
委員兼幹事邱新園科員
幹事何桂瑩科員
任期：104 年 1 月 1 日－105 年 12 月 31 日
111
二、衛生福利部豐原醫院病歷記錄品質審查及獎懲作業要點
一、病歷質之審查作業要點：依病歷審查要點辦理。
(一) 將所審查之病歷分為內、外科。
(二) 內科系之委員審查外科病歷，外科系之委員審查內科病歷。
(三) 審查分數基本為 100 分，各委員依審查表之項目，給予適量之分數。
(四) 每張審查表有主治醫師及住院醫師分數。
(五) 若分數高於 90 分者由第二位審查委員審查。
(六) 所審查之分數登記於質之分數表。
二、病歷質之審查
(一) 質之審查表分住院、急診、門診初診、住院中病歷審查。
(二) 採抽樣方式抽調醫師該月完成之病歷。
(1) 出院審查：依住院完成登記本，抽調每位醫師 1 本病歷，分內、外科填寫審查表且依病歷
填寫主治醫師及住院醫師，每 2 個月審查一次。
(2) 急診審查：每 2 個月抽調每位急診醫師一本急診病歷，填寫審查表。
(3) 初、複診門診病歷審查：每 2 個月抽調每位醫師初(複)診患者之病歷填寫審查表。
(4) 住院中病歷審查：
4.1 由病房主任執行住院中病歷審查
4.2 病房主任依責之病房，每週各審 3-5 本病歷。
4.2.1 審查主任依審查表項目逐一審查，並將審查建議填寫至建議欄內
4.2.2 審查表第一聯送回歷室統計，第二聯（複寫聯）置放住院病歷中，回饋該醫師改進
　　　　　　或維持
4.3 病歷室將第一聯審查結果統計，於次月病房主任會議中報告結果，病歷室將統計結果
上網公告。
(5) 調閱病歷時，依借閱規則應填寫病歷調閱單，並註明為審查用，以利追蹤。
三、統計工作：
(一) 依各醫師病歷完成之情況每月統計月報表，並於醫務會議報告完成情況。
(二) 住院中病歷質審查，每月統計結果於醫務會議報告。
(三) 依出院病歷值得審查之統計分數高於 90 分中取名次，於醫師節獎勵。
(四) 依本院醫師書寫獎懲辦法，每月統計量〈份數〉，填入評分表，提報醫師獎勵發放委員會
四、獎懲辦法
(1) 獎勵以分數高於 90 分取名次給予獎勵。
(2) 每年在醫師節，頒發病歷書寫優良獎狀。
(3) 分數低於 70 分者傳簡訊請醫師至醫行室查閱及改善。
112
三、出院病歷量審查作業要點暨獎懲辦法
一、病房書記將病歷於患者出院後 24 小時內送達病歷室簽收。
二、依病歷未完成審查項目，對住院醫師及主治醫師部分做逐項審查，對記載不詳或未完整之
病歷登錄電腦，列印未完成通知單，並將未完成通知單夾於病歷封面，告知醫師病歷應完成項
目。
三、對醫師未完成病歷，先單獨通知再傳呼及群呼或上網公告通知各醫師至病歷室完成。
四、再將每位醫師已完成病歷登錄電腦。
五、每個月在醫務會議公告醫師未完成排行榜。
六、依照未完成項目逐項審查，並列印未完成單夾於病歷上。
衛生福利部豐原醫院頁數：0001

醫師未完成病歷通知單日期：
105/xx/xx
◎醫師：XX XX ~ XX XX ◎通知日期：105XXXX—105XXXX 編號：HH_FIN02
醫師通知日期應完成日期姓名病歷號碼
000 黃 XX 093/04/16 093/04/20 黃 xx 27xxxx

999 陳 XX 093/04/18 093/04/23 謝 xx 24xxxx
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七、出院病歷書寫獎懲辦法
1 醫師書寫獎勵:
1.1 該本出院病歷 5 日(含日歷日)內完成：主治醫師每本各 100 點。
1.2 住院醫師 3 日內完成每本各 100 點(住院醫師 4-5 日不罰扣)。
2.醫師書寫罰扣:
2.1 住院醫師
2.1.1 超過 5 日者(含日歷日)，每日每本罰 50 點採個別罰扣。
2.1.2 該月 5 日未完成率未達 80%，每日每本罰 100 點採個別罰扣。
2.2 主治醫師
2.2.1 為住院醫師完成日為通知日期，完成期限為 2 天，第三天起每日每本罰 50 點
　　　採個別罰扣。
3.專科護理師獎懲
3.1 獎勵方式
3 1.1 助理每月完成筆數超過 15 本以上，3 日內完成率 90%加獎勵金 4 點
3.1.2 助理每月完成筆數超過 15 本以上，3 日內完成 90%，且該月主治醫師 3
日內完成 90%加獎勵金 5 點
3.2.罰扣方式
3.2.1.未達 80%上網公告
3.2.2 未達 80%逾期每本扣 20 元(合計後換算成點値每單位 0.5 點)
3.2.3 未達 70%逾期每本扣 50 元(合計後換算成點値每單位 0.5 點)
4 出院病歷病房為 24 小時內送回病歷室。
4.1 星期六、星期日之出院病歷於星期一下午 4 點前送回病歷室，避免影響醫師書寫時效。
四、衛生福利部豐原醫院病歷借閱管理規則
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一、院內病歷，除有下列情形外，概不借出院外：
1.衛生、治安、司法或司法警察等機關因公必要時。
2.院內人員持有法院通知，需要病歷作辯護上之證明時。
二、外界如有特殊情形，須經主治醫師及院長核准，以影印本給予為原則。非經核准不得影印。
三、凡借閱病歷須填病歷借閱單，始准借閱，但不得攜出院外。病歷借閱單由院方自行印製。
四、院內醫師為學術上研究或統計之用時，得借閱病歷，每次不得超過廿份，並於 7 日內歸還；
續借時需續填借閱單，以一次為限。
五、各科門診診療後，醫師需要病歷做為醫療參考時，須填具借閱單，交由門診護士向病歷室
借閱，並於廿四小時內歸還。
六、院內護理人員借閱病歷，需經單位主管或主治醫師簽章，以在病歷室閱覽為限。
七、健保經辦人員及社會服務室工作人員，因公借閱病歷，須經主管核可後始准借出，並於一
週內歸還。
八、借閱病歷不得折角或污損。
九、借閱病歷除為醫療診斷需要，不得轉借或出示他人。
十、病歷借閱完畢，應交還病歷室經管人員，並將其入庫。
十一、借閱病歷逾其未歸還者，由病歷室負責催還，否則不得另借其他病歷；若有遺失不能交回，
由病歷室簽會人事室及政風室查明責任報請議處。
病歷借閱天數規定
借閱原因天數
醫師借閱 7
學術研究 7
保險公司病歷 14
健保抽審 7
健檢 3
病歷審查 7
申報審查 7
高額或特殊個案事前審核 3
法院勞保及公文調閱 14
預約住院 7
病歷影本 7
五、衛生福利部豐原醫院病歷摘要、影本發給要點
衛生福利部豐原醫院病歷複製本申請流程
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一、本院病歷複製本係依民國九十三年四月二十八日公佈修正醫
療法之規定辦理。
二、申請流程：
（一）得由本人或法定代理人、親自前來申請，
需正本證明文件(身分證或未過期駕照)
（二）若非本人可委託他人，需檢具載明委託意旨、
影印範圍之委託書，及雙方正本身分證
（三）收費標準(依衛生署 93.8.23 衛署醫管字第

0932900179 號函)
1、基本費用 200 元(含 10 張影本)。
2、病歷複製每張紙五元。
(四) 請先至掛號櫃檯申請並繳交基本費用，領
取當日視影本張數再收取影印費用。
（五）自申請日起 3 日至 14 日（請詳閱流程圖背面說明）
完成後，以電話通知前來領取，並填寫領具。
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衛生福利部豐原醫院病歷影本申請書
　一、病歷影印本係依民國九十三年四月二十八日公佈修正醫療法之規定辦理
　二、申請注意事項：
(一)得由本人或法定代理人前來申請，需正本證明文件 (身分證或戶口名簿) ，
並附影本乙份。
(二)若非本人可委託他人前來申請，需檢具載明委託意旨、影印範圍之委託同意書，
及雙方正本身分證，方可申請，並附影本乙份。
(三)收費標準：基本費用 200 元(含 10 張內)，第 11 張起病歷影印每張 5 元。
(四)申請當日請先至掛號櫃檯繳費(200 元)，領取當日視影印張數再補收費用。
(五)自申請日起 3 至 14 日（依衛生局規範）完成後，以電話通知前來領取，並填
寫
領具。
(六)□中文病歷摘要，每一科別每份 500 元，工作天數為 14 日。
(七)請填寫以下資料（若委託書已載明，不需填寫）
1. 病歷號碼或身分證號碼：
2. 病歷影本用途(請勾選)：
□ 1.提供保險公司：
□ 2.提供勞保局：
□ 3.提供健保局：
□ 4.供他院參考：
□ 5.兵役：
□ 6.法律用途：□繼承 □保險爭議 □意外求償 □醫療爭議
□ 7.其他(請載明原因)：
3. 影印範圍：
□ 1.部分
　　　科別：
期間：
備註：
□ 2.全部病歷
申請人：
法定代理人：
受委託人：
家用電話：
行動電話：
申請日期　　　年　　　　月　　　　日
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依台中市衛生局規定「病歷複製本之時限規範」辦理
一、出院英文病歷摘要工作天為三天(不含例假日)。
※於申請日前 7 日出院者，工作天為七天。
二、全本病歷複製本、門急診病歷複製本工作天三至十四天。
三、中文病歷摘要工作天 14 天。
四、若領取病歷複製本時，因路途遙遠不克前來，可委託他人領取，
請在申請書上註明委託人，屆時請受委託人攜帶身分證前來領取；
或可用郵寄方式，先預收影印費及郵資。
六、病歷資料之提供
一、本院對於病歷查詢作業一律採用函詢方式。
二、本院查詢對象及作業方式：
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(一) 保險公司(如南山人壽、國華人壽、中國人壽、郵局…….等)
1. 函詢一律至收發室收文
2. 查詢時必需檢附病人同意書，或保險要保書中有病人簽章願意讓保險公司至所診療之醫院
查詢診療記錄之同意聲明書的影印本，但需加蓋該公司及負責人之印章，並註明「被保險同意
書如發生爭議，由該公司負完全法律責任」。
3. 查詢時註明查詢重點。
4. 查詢費用每件 1000 元(現金、支票、匯票皆可，現金外抬頭需填寫「衛生福利部豐原醫院」。
5. 如該保險公司未附病歷摘要表，則使用本院統一之表格。
6. 作業流程：
(1)查詢病歷號及調病歷(須填寫調閱單放入紙夾，並註明查詢用以利追蹤。
(2)調出之病歷，需登記以利追蹤。
(3)敬會該主治醫師或診治醫師填寫病歷摘要表。
(4)若住院醫師填寫，需陳核該科主任核章。
(5)收費方式為：
a.逐件收費
b.累計收費：約 1-2 個月與保險公司結帳一次。
c.查詢費用繳交收文 3 日內掛號室入該填寫醫師之勞收。
(6)寄出方式有二：
a.將正本連同收據用掛號寄出。
b.保險公司窗口人員到院領回。
(7)公文以電子文處理方式陳核及存檔。
(二) 健保局及其他公務機關(如法院、衛生機關、警察局…….等)
1. 必需收文
2. 作業流程：
(1)查詢病歷號及調病歷。
(2)調出之病歷需登記以利追蹤。
(3)敬會該主治醫師，或診治醫師填寫病歷摘要表或所需之診療內容。如需影印病歷，需註明那
幾頁，後會病歷室。
(4)病歷將醫師回復內容以公文方式函復。
(5)影印所需之病歷資料。
(6)函稿並陳(需陳核病歷室主任、秘書、副院長、院長)。
(7)若為勞保局查詢，查詢費用 1000 元。
13.1 函稿並陳後，先敬會總務室開立收據。
13.2 發文至勞保局後，勞保局再寄 1000 元查詢費，給本院核銷。
13.3 收到查詢費後，除敬總務室出納，需加會計室。
(1) 陳閱後回病歷室，修改正確內容及發文日期，正本為函詢機關，副本為本院病歷
室。
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伍、病歷管理相關法令
1.醫療法第六十七條醫療法機構應建立清晰、詳實、完整之病歷。
前項所稱病歷，應包括下列各款之資料：
（1）醫師依醫師法執行業務所製作之病歷。
（2）各項檢查、檢驗報告資料。
（3）其他各類醫事人員執行業務所製作之紀錄。
醫院對於病歷，應製作各項索引及統計分析，以利研究及查考
2.醫療法第六十八條醫療機構應督導其所屬醫事人員於執行業務時，親自記載病歷或製作紀錄，
並簽名或蓋章及加註執行年、月、日。
前項病歷或紀錄如有增刪，應於增刪處簽名蓋章及註明年、月、日；刪改部份，應以畫線去除，不得
塗毀。
醫囑應於病歷載明或以書面為之。但情況急迫時，得先以口頭方式為之，並於二十四小時內完成書面
紀錄。
3.醫療法第六十九條　醫療機構以電子文件方式製作及儲存之病歷，得免令以書面方式製作；其資
格條件與製作方式、內容及其他應遵行事項之辦法，由衷樣主管機關定之。
4.醫療法第七十條　醫療機構之病歷，應指定適當場所及人員保管，病至少保存七年。但未成年者之
病歷，至少應保存至其成年後七年；人體試驗之病歷，應永久保存。
5.醫療法第七十一條醫療機構應依其診治之病人要求，提供病歷複製本，病要時提供中文病歷摘
要，不得無故拖延或拒絕；其所需費用，由病人負擔。
6.醫療法第六十三條醫療機構實施手術，應向病人或其他法定代理人、配偶、親屬或關係人說明手
術原因、手術成功率或可能發生之併發症及危險，病經其同意，簽具手術同意書及麻醉同意書，始得
為之。但情況緊急者，不在此限。
前項同意書之簽具，病人為未成年或無法親自簽具者，得由其法定代理人、配偶、親屬或關係人簽具
第一項手術同意書及麻醉同意書格式，由中央主管機關定之。
7.醫療法第六十四條醫療機關實施中央主管機關規定之侵入性檢查或治療，應向病人或其他法定
代理人、配偶、親屬或關係人說明，並經同意，簽具同意書後，始得為之。但情況緊急者，不在此限。
前項同意書之簽具，病人為未成年或無法親自簽具者，得由其法定代理人、配偶、親屬或關係人簽具
8.醫療法第七十四條醫院、診所診治病人時，得依需要，並經病人或其他法定代理人、配偶、親屬
或關係人之同意，商洽病人員診治之醫院、診所，提供病歷複製本或病歷摘要及各種檢查報告資料。
原診治之醫院、診所不得拒絕；其所需費用，由病人負擔。
陸、病歷資料之保密性
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一、病歷內容保密規定
1. 借閱病歷依本院借閱管理規則辦理，並登入電腦辦理借閱
2. 醫師受有關機關詢問或鑑定，不得為虛偽之陳述或報告。（醫師法第22 條〉
3. 醫師除依前條規定外,對於因業務而知悉他人秘密，不得無故洩漏。（醫師法第23 條）
4. 醫療機構及其人員因業務而知悉或持有他人之秘密，不得無故洩漏（醫療法第72 條）
5. 前屬醫師法第22 條所稱「有關機關」，依同法施行細則第八條規定，係指衛生、治安、司法或司
法警察等機關，是以醫師除對上開機關之詢問或委託鑑定，有依法陳述或報告之義務外，並無
對第三者提供病情資料之義務。又同法第23 條規定：「醫師除依前條（即前揭醫師法第22 條）
規定外，對於因業務而知悉他人秘密，不得無故洩漏。揆其規定意旨，蓋恐醫師任意提供病人資
料予第三者，
6. 有侵犯病人隱私權之虞。是以醫師若在病人同意情況下，將病情資料提供該特定第三者，自難謂
無故洩漏病人秘密。綜上所述，倘醫師及病人均同意將病情資料提供第三者知悉，應無違反法令
之可言。（衛生署75.4.2 衛署醫字第578914 號函）」
7. 勞工保險條例第二十八條規定及特約合約關係，交付被保險人之病歷摘要或其他病歷影本給勞
保局，應得免經病人配偶、親屬之同意，惟諸此雙方契約行為應不宜超越醫療法、醫師法等相關
法律之限制至於病人之病情，勞保局仍應遵守，公務員服務法及刑法規定，不得無故洩漏。如需
要非勞保特約之醫療所提供有關病歷資料，則以透過該院所在地衛生局索取之為宜。並以相關之
病摘要慧摘述與醫療機構收入或支出有關之資料為限。
8. 稅捐機構依稅捐稽徵法第三十條之規定調查課稅資料，認有必要要求醫療機構提示病歷資料文
件，醫療機構即得依醫療法第二十六條「依法令規定」逕予提供，尚無須再經醫療機構所在地之
衛生主管機關轉請索取之程序。（衛生署101.4.20 衛署醫字第1010066947號函）
9. 公務機關對個人資料之利用，應於法令職掌必要範圍內為之，並與蒐集之特定目的相符。但有下
列情形之一者，不得為特定目的外之利用：
A. 法令明文規定者。
B. 有正當理由而僅提供內部使用者。
C. 維護國家安全者。
D. 為增進公共利益者。
E. 為免除當事人之生命、身體、自由或財產上之急迫危險者。
F. 為防止他人權益之重大危害兒有必要者。
G. 為學術研究而有必要且無害於當事人之重大利益者。
H. 有利於當事人權益者。
I. 當事人書面同意（電腦處理個人資料保護法第八條）。
二、本院員工及新進人員需簽切結書且依照法律規範
保密切結書
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茲保證本人恪遵保密要求，無論在職、調職或
離職後，對於職務上所知悉、持有或偶然得知或偶然持有之
病患隱私或機密資料程式及其檔案、媒體、院內網頁內容等，
絕對保守機密，除法律規定及業務需要外，不得上網公佈或
經電子郵件或以其他方式對第三人或對外洩漏。如有違犯，
願自負法律責任。
敬啟
具結人
職稱：
姓名：
身分證字號：
中華民國年月日
122
柒、疑似性侵害病歷處理
1. 疑似性侵害之病歷、應另外存放保管並在病歷做註記。
2. 疑似性侵害病歷處理之病歷、若加害人為法定代理人、則無權利調閱或查詢資料。（依94年4閱12
日台中縣衛生局公示辦理）
3. 疑似性侵害病歷處理之病歷、若加害人為配偶則無權利調閱，亦不得用委託方式取行資料。
123
4. 敏感性病歷作業流程
4.1. 病歷簽收後，登記造冊，檔案加密
4.2. 紙本病歷封面加做註記
4.3. 將病歷裝入資料袋，進行彌封。
4.4. 另外存放於專用資料櫃，並加鎖保存。
4.5. 由專人管理，若須調閱病歷，依規定辦理之。
5. 敏感性病歷調閱注意事項及流程
5.1. 除本人、司法、衛生機關及法定代理人外，不得借閱獲知悉內容。
5.2. 若法定代理人為加害者亦不得調閱及知悉內容。
5.3. 調閱時必須登記。
5.4. 將資料裝入專用信封內，封好由轉人調送。
5.5. 借閱完畢後，需立即歸還。
124
捌、附錄
衛生福利部豐原醫院基本資料
住院中病歷品質審查表黏貼處
審查主任：
住院醫師、專科護理師：、年月日
審查項目：優可改進不適用
1.1 過敏史並註明日期及簽章
1.病歷首頁
1.2 紀錄血型
2.1 是否有替代方案
2.入院診療計
2.2 詳實並有醫師簽名或蓋章
劃說明書
2.3 病患或代理人同意之簽名
3.1 有記錄主要檢查、重要處置(手術)及抗生素使用
3.TPR sheet
3.2 治療內容能反應病況變化
4.Admission 4.1 於一天內完成
note 4.2 製作人簽名蓋章
5.Acceptance
note 或 transfer 5.1 於一天內完成
note
6.1 依 POMR 方式書寫詳實完整
6.Progress
6.2 Progress note 應每日記載並簽名(字跡清晰)
note
6.3 主治醫師核閱簽名、評論(需有日期)
7.Weekly
7.1 內容簡要清楚(未超過 7 天可不寫)
summary
8.1 手術(重要檢查)記錄完整(有圖解)，於 1 天內完
8.手術紀錄
成，並簽名
9.1 緊急會診於 2 小時完成
9 會診紀錄
9.2 一般會診於 24 小時內完成
9.1ICU 轉入轉出有醫師紀錄包括病名、手術/處置
9.2 主治醫師每日查房 2 次，並有記錄時間
10.ICU 紀錄 9.3 呼吸器的使用有治療參數及後續
9.4 臨床藥師、營養師固定評估用藥及營養狀況並紀錄
9.5 呼吸治療監測計畫
11.同意書、
10.1 手術、麻醉、侵入性檢查，有醫病雙方簽名內容完整
說明書
12.行動限制 11.1 有書面通知，家屬同意書
審查結果建議:
125
衛生福利部豐原醫院外科出院病歷品質審查表月
病歷號: 主治醫師: 住院醫師：
審查主任: 分數: 分數：
複審分數: 複審分數：　
出院日期:
審查項目：優可改未
1. 出院病歷 1.1 入院時診斷(寫全文) 2 2 1 0
摘要 22% 1.2 出院時主次診斷、手術合併症或併發症或致病之感染菌
種(寫全文) 2 2 1 0
1.3 簡要改寫主訴、現況病史未拷貝自入院摘要 3 2 1 0
1.4 住院治療過程詳實完整(如藥物治療、劑量，手術處置
方式結果及病理送檢等) 5 4 3 0
1.5 有意義的檢查及檢驗(包括有意義的結果分析說明) 2 2 1 0
1.6 出院時狀況(若為死亡應註記死因及日期) 2 1 0 0
1.7 對病人出院後的指示 2 2 1 0
1.8 有醫師完整簽章、有修改評論(加註簽章、日期為優) 2 2 1 0
2.1 主訴 PI、PH、PE、過敏史…等紀錄詳實完整 4 3 2 0
2.2 與診斷、性別重要之理學檢查執行及結果相符合 3 2 1 0
2.Admission
note 15% 2.3 初步診斷及治療計畫記載詳實完整 3 2 1 0
2.4 於一天內完成，並有簽名 2 2 1 0
2.5 主治醫師核閱簽名、評論(需有日期) 3 2 1 0
3.1 依 POMR 方式書寫詳實完整，應每日記載並簽名 ICU 每日須
記載 2 次並有記錄時間 5 4 3 0
3.Progress
note 3.2 所作之檢查有原因及結果之詳述 3 2 1 0
14%
3.4 交接班、轉科是否有紀錄，住院超過 7 日須寫 Weekly
summary、會診結果或臨床討論有詳實記載(若無此項目以病 3 2 1 0
程記錄記載內容評分)
4.1 手術時間紀錄 2 2 1 0
4.2 手術前後診斷及手術式 3 3 1 0
4.3 手術過程 3 2 1 0
4.手術紀錄 4.4 手術發現、切除或取出之器官部位、範圍需記錄 3 2 1 0
16%
4.5 應繪圖說明 2 1 0 0
4.6 麻醉方式 1 1 0 0
4.7 手術醫師及助手姓名及簽章 2 2 1 0
126
審查項目：優可續後頁
改未
5.醫囑單 5.1 抗生素、輸液、類固醇等用藥是否適當、其他藥物適應症 2 2 1 0
4%
5.2 應註記藥物過敏史並有醫師簽章於封面 2 2 1 0
6.TPR sheet 6.1 有記錄主要檢查、重要處置(手術)及抗生素使用 3 2 1 0
5%
6.2 治療內容能反應病況變化 2 2 1 0
7.1 入院診療計畫書詳實並有醫病雙方簽章 2 2 1 0
7.其它 4%
7.2 同意書醫師說明內容有記載並簽章 2 2 1 0
8.1 主訴症狀時間、病史、檢查檢驗結果、治療經過等
8.CT、MRI 8.2 臨床診斷及檢查目的，若短期重複檢查請詳述重複檢查原
20% 因 20 12 6 0
8.3 詳實紀錄檢查後結果 ○ ○ ○ ○
9.高貴抗
9.1 詳實記錄使用原因
生素
127
衛生福利部豐原醫院內科出院病歷品質審查表月
病歷號: 主治醫師: 住院醫師：
審查主任: 分數: 分數：
複審分數: 複審分數：　
出院日期:
審查項目：優可改未
1. 出院病歷 1.1 入院時診斷(寫全文) 2 2 1 0
摘要 1.2 出院時主次診斷、手術合併症或併發症或致病之感染菌
3 2 1 0
25% 種(寫全文)
1.3 簡要改寫主訴、現況病史未拷貝自入院摘要 4 3 2 1
1.4 住院治療過程詳實完整(如藥物治療、劑量，手術處置
方式結果及病理送檢等) 5 4 3 1
1.5 有意義的檢查及檢驗(包括有意義的結果分析說明) 3 2 1 0
1.6 出院時狀況(若為死亡應註記死因及日期) 2 2 1 0
1.7 對病人出院後的指示 3 2 1 0
1.8 有醫師完整簽章、有修改評論(加註簽章、日期為優) 3 3 2 0
2.1 主訴 PI、PH、PE、過敏史…等紀錄詳實完整 5 4 3 0
2.2 與診斷、性別重要之理學檢查執行及結果相符合 3 2 1 0
2.Admission
2.3 初步診斷及治療計畫記載詳實完整 4 3 2 0
note 18%
2.4 於一天內完成，並有簽名 3 2 1 0
3.1 依 POMR 方式書寫詳實完整，應每日記載並簽名 ICU 每日須
記載 2 次並有記錄時間 6 5 3 0
3.Progress
3.2 所作之檢查有原因及結果之詳述 4 3 2 0
note 20% 3.3 主治醫師核閱簽名、評論(需有日期) 5 4 3 0
3.4 交接班、轉科是否有紀錄，住院超過 7 日須寫 Weekly
summary、會診結果或臨床討論有詳實記載 5 4 2 0
4.醫囑單 4.1 抗生素、輸液、類固醇等用藥是否適當、其他藥物適應症 3 2 1 0

5% 4.2 應註記藥物過敏史並有醫師簽章於封面 2 2 1 0
5.TPR sheet 5.1 有記錄主要檢查、重要處置(手術)及抗生素使用 3 2 1 0
6% 5.2 治療內容能反應病況變化 3 2 1 0
6.1 入院診療計畫書詳實並有醫病雙方簽章 3 2 1 0
6.其它 6%
6.2 同意書醫師說明內容有記載並簽章 3 2 1 0
7.CT、MRI 7.2 臨床診斷及檢查目的，若短期重複檢查請詳述重複檢查原
20% 20 12 6 0
因
7.3 詳實紀錄檢查後結果 ○ ○ ○ ○
8.高貴抗
8.1 詳實記錄使用原因
生素
128 月
衛生福利部豐原醫院急診病歷品質審查表
病歷號: 主治醫師: 分數:
審查主任: 急診日期:
審查項目：優可改未寫
1.急診病歷 1.1 診斷 5 4 2 0
診斷 14% 1.2 檢傷分類/離去方式 5 4 2 0
1.3 診察醫師簽章 4 3 0 0
2.急診病史 2.1 主訴 8 6 4 0
23% 2.2 過去病史 4 3 2 0
2.3 理學檢查 8 6 4 0
2.4 藥物過敏，是否有註記於病歷封面並簽章 3 2 1 0
3.1 檢查檢驗是否適當 4 3 2 0
3.2 所作之檢查有原因及結果之詳述 4 3 2 0
3.3 輸液、藥物之適應症(是否重複、劑量是否正確) 4 3 2 0
3.急診處置
25% 3.4 處置的適當性且詳實紀錄 6 5 3 0
3.5 會診適當性、針對會診醫師回覆有做適當處置、
3 2 1 0
且有紀錄(若無此項以整體病歷記載優劣給分)
3.6 患者留觀之病程紀錄詳實記載 4 3 2 0
4.其它 4.1 患者轉歸有紀錄完整 4 3 2 0

8% 4.2 急診病情告知，並有紀錄及簽章 4 3 2 0
5.CT、MRI 30 25 18 0
5.2 臨床診斷及檢查目的，短期重複檢查，請詳述重
30%
複檢查原因 ○ ○ ○ ○
5.3 詳實紀錄檢查後結果
　　
129
月
衛生福利部豐原醫院門診病歷品質審查表
病歷號: 主治醫師: 分數:
審查主任: 門診日期:
審查項目：優可改未寫
1.藥物過敏欄及血型是否填寫並簽章 8 6 4 0
2.Chife Complaints（複診應有此次主訴記錄，與上次門診記
10 8 6 0
載內容不能完全相同
3.Past History、家族史、旅遊史、職業及工作概況 8 6 4 0
4.Present Illness 10 8 6 0
5.Physical Examination 包括身高、（必要的理學檢查，重要
10 8 6 0
或異常之檢查紀錄）
6.Impression（臆斷及必要之鑑別診斷治療效果） 10 8 6 0
7.Management 10 8 6 0
8.醫師簽章或蓋章（字跡清晰） 6 4 3 0
9.開立 CT、MRI 主訴症狀時間、病史、檢查檢驗結果、
10 8 6 0
治療經過等
10.開立 CT、MRI 臨床診斷及檢查目的，短期重複檢查，
10 8 6 0
請詳述重複檢查原因
11.開立 CT、MRI 詳實紀錄檢查後結果 8 6 4 0
130
說衛
院長批示病歷遺失原因說明遺
明生
作：失
臨病
病
歷
福
時歷單利
病遺位部
歷
，失豐
借
遺閱原
失單醫
病位院
歷或病
尋人
獲員歷
或應遺
出會病失
現同患
時診
姓請
名
應治示
立醫單
即師
合檢
併齊
歸有
檔關
銷
X
案光遺病
及單失政醫歷
各位病風行號
項歷室室
年
碼
檢
驗
報月
告
，
送
病日
歷
室
製
131

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衛生福利部豐原醫院

It is generally recongnized that one of the most important function of a

The record should be sufficiently accurate and complete to lead itself to

The purpose of the history is to record an intelligent, logical and

but also of the patient as an individual.

State the complaints in single descriptive 〈in so far as possible, not

eating and bowel movements.

It must be emphasized that to name a disorder and accept "yes" or "no" is

3. Vaccinations and Sera 〈Dates〉

Record date, symptoms, diagnosis,treatment, name of doctor and hospital.

vessels, disc, retina and media.

oder, cholemic breath etc.〉 ; oral hygine; lips,teeth,gingivae and

Right Interspace Left

The description of auscultation should include rate 〈with

〈1〉 Grade III apical pansystolic blowing murmur transmitted to

〈2〉 Following loud opening snap, Gr. III apical middiastolic

Note the distension and abnormal pulsation of neck veins.

The patient should be draped to avoid unnecessary exposure. As a

protection to the examining physician, the nurse remains inattendance after

11. Rectal Examination

b. Provisional diagnosis（暫時診斷）入院時之暫時診斷不可簡寫或縮寫（ Do not

 主訴：Shortness of breath since last night

HCC. p’t Gastric Traffic

Nervous system：Mentality-well orientation, registration, attention and calculation

Admission Note （外科）

Admission note (小兒科)

No dysuria, No nocturia, No polyuria, No oliguria.

Date(Time) R.B.C 紅血 W.B.C 白血 Hemoglobin Hematocrit Platelet c

◆Percussion: normal liver and spleen span,

Back&spine：normal curvature, no open wound, no scar,

Mechanical axis 18 degree varus 2degree varus

◆Cranial nerves: intact

<Functional status> Rolling to R/L: D/I

<Functional Independence Measure, FIM>

Date(Time) R.B.C 紅血 W.B.C 白血 Hemoglobin Hematocrit Platelet c

Date(Time) R.B.C 紅血 W.B.C 白血 Hemoglobin Hematocrit Platelet c

(13)主 訴 Intermittent cough with bloody sputum for one month

(15) Review of system：

Nervous system ： Mentality-well orientation, registration, attention and

斷 1. Borrmann type III advanced gastric cancer, antrum

(13)主訴 Intermittent abdomen pain for 3 months.

(15)體檢發現 【The Major Findings of Physical Examination On Admission 】

No using of acceaaory-aspiratory muscles. No Central Venous Catheter noted.

●Back：Knocking pain:(-) Radiation pain:(-), No compression sore wound.

(18)合併症 no fever, no nausea/vomiting, no wound infection

Date(Time) PH 比重檢查 蛋白質定性 糖定性檢查 尿膽素原檢

Date(Time) R.B.C 紅血 W.B.C 白血 Hemoglobin Hematocrit Platelet c

Date(Time) R.B.C 紅血 W.B.C 白血 Hemoglobin Hematocrit Platelet c

Date(Time) PT(INR) PT(sec") APTT

Date(Time) R.B.C 紅血 W.B.C 白血 Hemoglobin Hematocrit Platelet c

Date(Time) W.B.C 白血 Hemoglobin Platelet c N-Seg Lymph

Date(Time) R.B.C 紅血 W.B.C 白血 Hemoglobin Hematocrit Platelet c

26.100 32.700 79.800 14.700 17.200

Date(Time) W.B.C 白血 Hemoglobin Platelet c N-Seg Lymph

Date(Time) pH PCO2 PO2 HCO3act tCO2

Date(Time) BNP 利鈉激

Date(Time) 肌酸磷化脢 CK-MB Troponin I CK-MB mass

Date(Time) pH PCO2 PO2 HCO3act tCO2

Date(Time) BUN(Blood) Glucose(AC Ca(Blood) Creatinine Na 鈉(boold

Date(Time) pH PCO2 PO2 HCO3act tCO2

Date(Time) BUN(Blood) Glucose(AC Ca(Blood) Creatinine Na 鈉(boold

Date(Time) BUN(Blood) Glucose(AC Creatinine Na 鈉(boold K 鉀(Blood)

Date(Time) BUN(Blood) Ca(Blood) Creatinine Na 鈉(boold K 鉀(Blood)

Date(Time) BUN(Blood) Glucose(AC Ca(Blood) Creatinine Na 鈉(boold

(13)主訴 Intermittent cough with bloody sputum for one month

(15)體檢發現【The Major Findings of Physical Examination On Admission 】

Date(Time) PH 比重檢查蛋白質定性糖定性檢查尿膽素原檢

Date(Time) Triglyceri P(Blood)磷鎂 Mg (Mag Taansferri Prealbumi

診斷醫師: 舒惠芬病解專醫字第 000209 號

通知:1010504 15:55 楊聰鎰一般會診外科回覆:1010504 17:08 匡勝捷

(16) 手術日期 00/00/00 Under GA -> laparoscopic right side salpingo-oophorectomy

(17) 住院治療 00/00/00 Admitted via ER for pre-OP preparation

(24)出院指示處----------置-----------名----------稱次劑量單位服法天總---量單

(23)出院情況術後傷口癒合良好,故予辦理出院並預約 0000-00-00 下午耳鼻喉科回診治療.

姓名：黃○○ 性別:女 Age:31 歲床號:1303-01 病歷號碼:4○1○5○

手術發現： Right knee ： adranced osteoarthritis -> joint space

姓名：王○○ 性別：男年齡： 38 病歷號碼：

斷手術後: 1) obstructive aleep apnea 2) chronic tonsillitis

衛生福利部豐原醫院頁數：0001