對於所有準備跨出專科護理師的朋友們,對於繕寫入院病摘的病程紀錄時常很困擾,特別是書寫的順序與方法,尤其是要用英文打時不知從何下手,因此將下列原則把握,對於未來要走專師的人,會有幫助的。

HPI  (History of Present Illness)  書寫注意事項

HPI問診完書寫需整理,原則依據下列:

  1. CC(Chief Complaint)抓住與診斷最有關係
  2. HPI要寫成句的句型
  3. HPI第ㄧ句指出個案年齡性別重要過疾病及強調cc故來看診
  4. 依據OLDCAR(何時發生、位置、多久、特徵、其他相關症狀、解除方法、做何處置?)
  5. 懷疑疾病之症狀確切有無效,此時多為…is (are) denied, He/She denied…
  6. 下一段可寫有關疾病與這次有關問題

CC. “I have pain in my chest and arm”

HPI.

Mr.(性別) F (主詞) is (動詞) a 55-year-old (年齡) advertising executive(職業) who comes to the emergency room complaining of pain (主訴)in his chest (位置) that began 1 hour ago (發生時間).1  He(主詞) describes (動詞、現在描述故用現在式) the pain (子句主詞) as pressure (特徵) under the sternum that radiates (子句動詞因為現在還會有痛可能故用現在式,CC特徵) into his left arm and up into his jaw.2 

On a scale of 1 to 10, he(主詞) rates(動詞,因為現在打分數故用現在式) it as a 7 in intensity (CC特徵).3 He(主詞) feels(動詞) short of breath (相關症狀).4 He(主詞) has had(動詞,因為他重兩週前到現在一直有症狀,故用現在分詞) similar symptoms during the last 2 weeks(在過去的兩週,請不要寫最近兩週the recent 2 weeks,英文不這麼寫), but(連接詞,故後面用ㄧ個有主詞及動詞句型) these episodes(主詞) have lasted(現在分詞) for 5 to 10 minutes(每次發生時間duration) at the most.5 He (主詞) noticed(動詞表示當在痛時注意到,故用過去式) that(子句連結字) the symptoms (指前面有關痛症狀是特徵子句主詞) are brought(主詞是無生命故用被動語態) on by climbing the stairs and(and連接字,是指前一子句與後一子句對等但同一主詞故省略) are relieved (動詞被動)with rest.6  Right now(請不要寫this time), he(主詞) reports(動詞) nausea and sweating(相關症狀,個案現在有此問題).7 

He(主詞) was given(被動,因為他被給予) sublingual nitroglycerin(處置) by the triange nurse in the emergency room, which (後面要接子句,動詞是指前面NTG) has helped(動詞用現在完成式,表示個案以前痛也曾給NTG) to ease the pain(處置).8 

      Mr. F has smoked one pack of cigarettes per day since the age of 15.  He drinks alcohol socially and does not use illicit drugs. (因為抽菸與該就診可能有關係,故這裡可在強調出,habbits也需再呈現)

        His family history reveals that his father died of an acute myocardial infaraaction at age 50; his mother, currently living, has hypertension.  His paternal grandfather died of an cute myocardial infarction at age 45. (因為家族史與個案就診可能有關,故這裡敘訴,family history也需再呈現)

 

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