4、輸血申請單[Blood bank requisition form]
(1)reason for infusion[輸血原因]
▲紅細胞[packed red cells, wshed RBCs]:
*Hb<8.5 [血色素<8.5]
*>20% blood volume lost [>20%血容量丟失]
*cardio-pulmonary bypass with anticipated Hb <8[心肺分流術(shù)伴預(yù)計血色素
<8]
*chemotherapy or surgery with Hb <10[血色素<10的化療或手術(shù)者]
▲全血[whole blood]:
massive on-going blood loss[大量出血]
▲血小板[platelets]:
*massive blood transfusion >10 units[輸血10單位以上者]
*platelet count <50×103/μl with active bleeding or surgery[血小板<5萬伴活
動性出血或手術(shù)者]
*Cardio-pulmonary bypass uith pl<100×103/μl with octive bleeding[心肺分流
術(shù)伴血小板<10萬，活動性出血者]
*Platelet count <20×103/μl[血板<2萬]
▲新鮮冰凍血漿[fresh frozen plasma]:
*documented abnormal PT or PTT with bleeding or Surgery[PT、PTT異常的
出血或手術(shù)病人]
*specific clotting factor deficiencies with bleeding/surgerg[特殊凝血因子缺乏
的出血/手術(shù)者]
*blood transfusion >15units[輸血>15個單位]
*warfarin or antifibrinolytic therapy with bleeding[華法令或溶栓治療后出血]
*DIC[血管內(nèi)彌漫性凝血]
*Antithrombin III dficiency[凝血酶III 缺乏]
(2)輸血要求[request for blood components]
*patient blood group[血型]
*Has the patient had transfusion or pregnancy in the past 3 months? [近3個月，
病人是否輸過血或懷孕過？]醫(yī).學(xué) 全,在.線,提供www.med126.com
*Type and crossmatch[血型和血交叉]
*Units or ml[單位或毫升]
5、出院小結(jié)[discharge summary]
Patient Name[病人姓名]
Medical Record No.[病歷號]
Attending Physician[主治醫(yī)生]
Date of Admission[入院日期]
Date of Discharge[出院日期]
Pirncipal Diagnosis[主要診斷]
Secondary Diagnosis[次要診斷]
Complications[并發(fā)癥]
Operation[手術(shù)名稱]
Reason for Admission[入院理由]
Physical Findings[陽性體征]
Lab/X-ray Findings[化驗及放射報告]
Hospital Course[住院診治經(jīng)過]
Condition[出院狀況]
Disposition[出院去向]
Medications[出院用藥]
Prognosis[預(yù)后]
Special Instruction to the Patient(diet, physical activity)[出院指導(dǎo)（飲食，活動量)]
Follow-up Care[隨隨訪]
6、住院/出院病歷首頁[Admission/discharge record]
•Patient name[病人姓名]
•race[種族]
•address[地址]
•religion[宗教]
•medical service[科別]
•admit (discharge) date[入院（出院)日期]
•Length of stay [住院天數(shù)]
•guarantor name [擔保人姓名]
•next of kin or person to notify[需通知的親屬姓名]
•relation to patient[與病人關(guān)系]
•previous admit date[上次住院日期]
•admitting physician [入院醫(yī)生]
•attending phgsician[主治醫(yī)生]
•admitting diagnosis[入院診斷]
•final (principal) diagnosis[最終（主要)診斷]
•secondary diagnosis[次要診斷]
•adverse reactions (complications)[副作用（合并癥)]
•incision type[切口類型]
•healing course[愈合等級]
•operative (non-operative) procedures[手術(shù)（非手術(shù))操作]
•nosocomial infection[院內(nèi)感染]
•consutants[會診]
•Critical-No. of times[搶救次數(shù)]
•recovered-No. of times[成功次數(shù)]
•Diagnosis qualitative analysis[診斷質(zhì)量]
OP.adm.and discharge Dx concur [門診入院與出院診斷符合率]
Clinical and pathological Dx concur[臨床與病理診斷符合率]
Pre- and post-operative Dx concur [術(shù)前術(shù)后診斷符合率]
•Dx determined with in 24 hours (3 days) after admission[入院后24小時（3 天)內(nèi)確診]
•Discharge status[出院狀況]
recovered[治愈]
improved[好轉(zhuǎn)]
not improved[未愈]
died [死亡]
•Dispositon[去向]
home[家]
against medical ad[自動出院]
autosy[尸檢]
transferred to[轉(zhuǎn)院到]
