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珍农从
7 years ago
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2 1-1 (medical record)

3 01 3

5 (history) (chief complaint) (present illness) (past history) (personal and family history) (review of systems) 2. (physical examination) 3. (physician s order) 4. (daily observation note) (progress note) (nursing note) (vital sign sheet; TPR sheet) 5. (reports of laboratory examination and other specific diagnostic tests) 6. (operation note) 7. (anesthesia record) 8. (consultation report) 5

systems) 2. (physical examination) 3. (physician s order) 4.

6 9. (discharge summary) 10. (patient education/instruction) 1. (demographic information) 2. (financial information) 3. (consents and authorizations) 1-3 6

7 01 (chief complaint) (present illness) (past history) (personal and social history)(family history) (review of systems) (physical examination) (impression) (tentative diagnosis)(plan) (patient education) (follow-up) 1. (subject) 2. (object) 3. (assessment) 4. (plan) 1. (front sheet) 2. (order sheet) (1) (2) (3) 7

(impression) (tentative diagnosis)(plan) (patient education) (follow-up) 1.

8 (4) (5) (TPR sheet) (T) (P) (R) (BP) (I/O) 4. (admission note) (1) (chief complaint) (symptoms) (time of onset) (mode of onset)(duration) 1-1 (2) (present illness) 1-1 (3) (past history) 1-1 8

9 01 (4) (personal, social and occupational history) 1-1 (5) (family history) 1-1 (6) (review of systems) 1-2 (7) (physical examination, PE) 1-3 9

10 1-1 (chief complaint) (present illness) (past history) (personal, social and occupational history) (family history) (gestation, G) (parturition, P) (spontaneous abortion, SA) (artificial abortion, AA) (cesarean section, C/S) (preeclampsia)

(gestation, G) (parturition, P) (spontaneous abortion, SA)

11 (general appearance) (skin) (head) (eyes) (ears) (nervous system) (musculoskeletal system) (cardiovascular system) (gastrointestinal and hepatobiliary system) (respiratory system) (genitourinary system) (endocrine system) (hematologic system) (mental status) (8) (laboratory and image) (9) (impression / tentative diagnosis) (10) (plan) 11

system) (respiratory system) (genitourinary system) (endocrine system) (hematologic

12 1-3 (general appearance) (vital signs) (head) (neck) (eyes) (ears) (nose) (oral cavity) (throat) (chest) (heart) (breast) (gastrointestinal tract) (male genital organs) (female genital organs) (rectus and anus) (lymphatic system) (nervous system) (peripheral vessels) (saturation of blood oxygen, SaO 2 ) (postauricular hematoma, battle sign) (jugular vein engorgement, JVE) (lymphadenopathy, LAD) 12

(rectus and anus) (lymphatic system) (nervous system) (peripheral vessels) (saturation of blood

13 01 5. (progress note) (1) (progress note) SOAP S: Subjective data O: Objective data A: Assessment P: Plan (2) (weekly summary) (3) (off-service and on-service note) 6. (consultation note) (impression) (diagnosis) 7. (invasive procedure record) 13

summary) (3) (off-service and on-service note) 6.

14 8. (operation note) (preoperative evaluation)(operation method) (operative finding) 9. (anesthesia record) 10. (medication record) 11. (nursing note) (1) (2) 14

15 01 (3) (4) (5) (6) 12. (discharge summary) (1) (2) (3) (4) (5) (6) (7) 15

16 (8) (9) (10) (11) EMT 16

17 01 3. (1) (2) (3) (4) ICU 17

18 ( )1. (A) (B) (C) (D) ( )2. (A) (B) (C) (D) ( )3. (chief complaint) (A) (B) (C) (D) (time of onset) ( )4. (1) (2) (3) (4) (5) (A)(2)(3)(4) (B)(1)(2)(3)(4) (C)(1)(2)(5) (D)(1)(2)(3)(5) ( )5. (progress note) (A)S, subjective data (B)O, objective data (C)A, action (D)P, plan ( )6. (A) (B) (C) (D) ( )7. (A)6 (B)12 (C)24 (D)48 ( )8. (A) (B) (C) (D) BDABC CCA 18

19 PRIEVIEW

20 Admission Note Internal Medicine, 60 years old, male, married, businessman. Date of admission: Chief Complaint: Shortness of breath, mild fever, poor healing wound on the left plantar region for months. Present Illness: This 60-year-old male patient had history of type 2 DM for 5 years with regular medical control (Novomix 38 IU BID) at our OPD follow up. The latest HbA 1c level was 12.2%. However, he suffered from mild fever with cough and sputum formation in recent a week. He also had the on and off attack of urinary tract infection. Besides, he had one poor healing wound on his left plantar region, and his foot swelled in the winter. In recent 3 days, swelling, heat sensation, redness was found on his left foot, and he felt fatigue and poor appetite, therefore, he visited our OPD this morning, and BS>500mg/dL was noticed. Then he was referred to our ER, where a series of LAB examinations disclosed leukocytosis, hyperglycemia (BS=673mg/dL), acute in chronic renal failure, hyponatremia, mild hyperkalemia, and marked elevated CRP level. Urine examination showed pyuria and bacteria (++). He was admitted to our ward for further management. Past History: 1. HCVD and Af with medical control (Urosin 1# PO QN, Fedil 1# PO QD). 2. The history of major operation: Diabetic retinopathy, OS s/p and cataract. 3. No known food or drug allergy. 20

Present Illness: This 60-year-old male patient had history of type 2 DM for 5 years with regular medical control (Novomix 38 IU BID) at our OPD follow up. The latest HbA 1c level was 12.2%.

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