【病歷書寫規範】

行政院衛生署豐原醫院病歷書寫規範
96年10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〉行政院衛生署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
〈二〉外科實例
〈三〉小兒科實例
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〈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
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肆、行政院衛生署豐原醫院病歷管理規章
一、行政院衛生署豐原醫院病歷委員會設置要點
二、行政院衛生署豐原醫院病歷品質審查及獎懲作業要點
三、行政院衛生署豐原醫院病房病歷管理要點
四、行政院衛生署豐原醫院病歷借閱管理規則
五、行政院衛生署豐原醫院病歷摘要、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、行政院衛生署豐原醫院病歷審查表（量的審查）
二、行政院衛生署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，應合併於最先建立之病歷；
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)
或類似子句處方可以Ditto 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、「出院診斷」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24小時(逢假日則順延)內完成，並送達病歷室。
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。
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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
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27.8cm
(一 ) 一一一一一一 (一一一一一一一 (一一一一一一一 ))一 21.627.5cm一
(一 ) 一一一一一一一一一 74mm一一一一一 7mm一一一一一一一 7mm一一一一一一 98(95)mm一
(一 ) 一一一一一一一一 21.627.5cm一一一一一一一一一一 24.9mm一一一一一一一一一
6mm一一一一一一一一一 12mm一一一一一一一一一23mm一
一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一 (ICD-9-
CM)一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一 (一一一一一一一一一 )一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一
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一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一一一一一一一一
一一一一一一一一一一
一一一一一一一一一一一一一一一一一一一一
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二、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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門診病歷排列順序如下：
1.門診病歷封面
2.門診初診病歷
3.病歷二號紙(急診單張依時間順序及二頁紙空格置放於二頁紙前或後)
4.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)
5.各科大張檢查報告單
6.檢驗報告粘貼紙
一、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(一)(二)
3.Admission Note(各科專用住院病歷)
4.Progress Note(病歷二號紙填寫)
5.會診單
6.麻醉記錄
7.手術前後交班記錄
8.手術記錄
9.手術前後 X 光影像圖
10.手術室護理記錄
11.麻醉前評估調查表
12.恢復室記錄
13.ICU 轉入評估表
14.分娩記錄
15.產程記錄
16.產後護理記錄
17.轉介病歷摘要
18.他院之病歷摘要或報告單
19.各科特殊表單及各科大張檢驗報告單
20.小張報告粘貼單
21.病患自控式止痛法使用麻醉藥品醫囑單
22.長期醫囑單
23.安寧病床持續疼痛評估表
24.臨時醫囑單
25.體溫表
26.投藥與治療單
27.監護記錄
28.ICU 治療記錄
29.Neurological Record
30.血壓脈博呼吸和瞳孔記錄
31.胰島素注射部位記錄單
32.患者翻身記錄單
33.輸入和輸出記錄單
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34.營養照護記錄
35.護理指導紀錄單
36.社會工作照會單
37.護理記錄，護理照護摘要紀錄單
38.新生兒護理記錄
39.護理計劃表，復健科住院計劃書
40.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
41.入院護理摘要
42.出院護理摘要
43.手術自願書、麻醉自願書
44.自願退院書
45.死亡證明診斷書
46.入院許可證
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
二、精神科急性病患病歷排列順序
三、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。
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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 diagnostic〉 word or phrase in patient's own language with duration.
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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 sequelae.
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
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hospital. 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,hyper
tension, 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
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should also be included. This may be obtained from nurses' notes.
Development, apparent nutritional status, habitus, apparent age compared
with actual. 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：
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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
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
16
---------------------------------------------
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.
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
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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,
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
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〈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
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.
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〈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
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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
籍貫、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，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：
Chief Complaint Present Illness Past History Impression
Family History Physicial Examination 診療計畫
（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
往後之醫師瞭解。.
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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
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！
（4）出院病歷摘要（Discharge Note 或Discharge Summary）：
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 .處理經過及特殊記載
f.出院後之建議
出院病歷必需儘早完成，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。
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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：
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、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
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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。
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，三天之內應至少記載一次（只有星期日及國定假日可不記）。
8、病歷記載要負責，因此一定要簽名，而且是簽全名。
有個人職章時應蓋章，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。
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）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、籍貫、戶籍所在地
通訊地址、國民身分証字號、職業、電話、婚姻狀況、本院初診日期及聯絡人。
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. 各科部初診及歷次住院記要
各科部門診初診應填寫科部別及初診日期，若有住院事實則負責醫師需填明科部別、入出院
日期、年齡、診斷及預後並蓋章或簽名。
5. 藥物過敏史
由醫師以紅筆註記警示。
〈二〉門診病歷
1. 初診
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。
．若應診目的只為繼續拿藥，可寫"ditto" 或"drug only" 或"Do"。
門診寫"Do"時，應註明Do 那一天之診斷及藥品，並應簽名。時間過久者，應重新載明診斷及醫
囑。
．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」，前者由病歷室擔任，後者由病歷委員會的委員擔任。
1. 量的審查
每本出院病歷由病歷室疾病分類人員依「行政院衛生署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，每月結算三次，分別為每月10號、20號和30號，上網公告
逾期排行榜，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，一律
25
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）
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「行政院衛生署豐
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副簽，簽全名
或蓋章。
〈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，住院醫師應予副簽。
〈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。
．Admission note（入院記錄）
．Physical exam.（體檢發現）
．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
體溫、脈搏、呼吸記錄單上的特殊用藥記錄，如抗生素、化學治療用藥等必須註明。
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）
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．Procedure（術式）
．Description（說明）
包括operation finding, operation procedure，圖示等。
．Signature（簽名）
必須由住院醫師級以上醫師簽全名或蓋章。
〈7〉 Order sheet（醫囑單）
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）
．凡是腰椎麻醉或全身麻醉的病人都應有麻醉記錄單。
．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）
2. 質的審查
依照「行政院衛生署豐原醫院病歷品質及獎懲作業要點」辦理，每月由病歷管理委員會之委員審查
依「行政院衛生署豐原醫院住院病歷記錄品質審查表」作抽樣審查。審查結果送出主治醫師前5名、
住院醫師前3名給予獎勵，按月陳核病提供資料至獎勵金委員會。
〈五〉行政院衛生署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，對其治療計劃或預後會有很大影響，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）
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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。
〈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蓋章才算完成。
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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（內科）
General Data:
Name: 000 Gender: Male Age: 81 years old
Height: 170 cm Body Weight: 69 Kg Date of Admission: 00/00/00
Chart No: 00000000 Admitted Room : 2517
Date Source: Patient Occupation: retired farmer
Chief Complaint: Intermittent cough with bloody sputum for one month
Present Illness:
This 81 y/o male patient was an exsmoker (1PPD for 50 years and has quit for 4 years). He was
relative well in the past except benign prostate hyperplasia s/p transureteral resection of prostate on
00/00/00 and 00/00/00. Then the symptom of dysuria was improved.
This time, he says he occasionally coughed up about 10 cc of blood streak sputum twice a day in
recent one month. The symptoms spontaneous stopped within 2-3minutes. Besides, sometimes dullness
localized anterior chest pain when he deeply inspiration was noted in recent one week. He denies fever,
alcohol drinking, any known exposure to TB, recent pneumonia history, recent hoarseness, familial
history of lung cancer, symptoms of bleeding problems, e.g., bleeding gums, frequent bruising, difficulty
stopping bleeding, exertional dyspnea, recent weight loss or melena. Therefore, he came to our hospital
and was evaluated in the OPD. CXR revealed a cavitary mass without satellite lesion over right lower
lung field. Under the impression of hemoptysis, R/O lung cancer or lung abscess. He was admitted to our
ward for further evaluation and treatment.
Throughout the course of the disease, there was no skin lesion, consciousness change, fever or
dyspnea, but cough with bloody sputum was noted.
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:
30
UTI
HCC. Sepsis
HCC. p’t Gastric Traffic

ca. Accident
Review of system:
1. Systemic: fever (-), BW loss (-), easy-fatigibility (-), 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 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: (+/+)
31
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
32
Tendem walking and Romberg test: OK
Lab:
1. CBC: (Date: 00/00/00)
WBC: 6.4 K/UL (DC: 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:
Impression:
1. Hemoptysis, R/O lung cancer, R/O lung abscess
Plan:
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.
33
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
主任醫師蓋章: 主治醫院蓋章:○○○ 住院醫師蓋章:○○○
34
ADMISSION（外科）
病歷號碼:00664437 00/00/00 00:00
衛生署豐原醫院姓名:江○○
住院序號:00000000000 床號:2ICU-29
出生日期:00/00/00 性別:男
------------------------------------------------------------------------------------
§日期︰00/00/00 §時間︰00︰00 §醫師︰○○○
------------------------------------------------------------------------------------
■ 主訴
Massive left-side pleural effusion noted on chest X-ray image for more than 10days.
■ 病史
This 74y/o man with a past history of old CVA, chronic respiratory
failure with depending on ventilator suffered from left side pleural
effusion since 00/00/00 and Chest CT examination was performed on00/00/00.
Massive pleural effusion of left thoracic cavity was noted and chest
tapping pleural fluid study showed bloody appearance and tumor survey
showed Higher CA-199 level(32.34). Under the impression of parapneumonic
pleural effusion, he was referred to our hospital on 00/00/00 for thoracic
endoscopic examination.
Tracing his relational history, he was sent to 衛生署○○醫院 on
00/00/00 due to SOB and vomiting with coffee-ground material. After RLL
pulmonary infiltration was noted with CXR and respiratory failure,
endotracheal intubation was performed and transferred to ICU for intensive
care under the impression of aspiration pneumonia with upper GI bleeding.
Owing to prolonged ventilator support, tracheostomy was performed on
00/00/00. Tumor survey was also performed on 00/00/00, AFP=2.05, CEA=2.51,
PSA=0.605, CA-199=32.34.
【Past History of Major Systemic Diseases】
Old CVA with right hemiplegia
Gastric cardia ulcer with antral gastritis. (PES:00/00/00), DM, type 2 with
regular control.
Hypertension with CHF,
Renal diseases: High Cr level
noted:2.5(00/00/00),3(00/00/00),2.8(00/00/00),
3.5(00/00/00),4.4(00/00/00). U/A showed Proteinuria.
Chronic Anemia:Hb level between 8.5-10.7g/dl
Asthma(-), COPD(-), Liver Diseases(-),
Allergy(-)
【Personal Habitude】smoking(-), alcoholic drinking(-),

【 Family History 】DM(-), CVA(-), HTN(-), Tumor(-) All denied.
【Operative History】Tracheostomy on 00/00/00
Debridement on 00/00/00
■ 體檢發現
【The Major Findings of Physical Examination On Admission 】
●Consciousness：alert, but sometimes confused.
●Coma Scale：E(4)M(6)V(T)
●General appearance: chronic ill-looking. Weakness. Right hemiplegia.
skin turgor: dry and loose. No tremor. Muscle power: all 4+
●Vital Signs：BP=175/83mmHg, PR=69/min, RR=12/min, BT=36℃
●BH=about 170cm, BW=about 55kg.
●HEENT：
◇Head：no open wound, no scalp hematoma, no hair loss, no scar, no
tenderness
35
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.
tracheostomy tube in place without discharge and depended on
ventilator(Pressure support mode)
●Chest：,
no using of accessory-respiratory muscle,
symmetric expansion, intermittent shortness of breathing,
︵ no subcutaneous emphysema, no open wound of chest wall.
∕ ﹨
｛`︷'｝Heart sound：regular rhythm without murmur. No click, No thrill.
╰─╯ Breathing sound：rales over left side. No wheezing.
╴ ∕ ﹨＿ ●Abdomen：
∕ ＼〒／ ﹨ Soft, not guarded. Scaphoid in appearance.
﹨Bowel Sound：normal active.
﹨ ⊙ ⊙∕ Liver/Spleen:nonpalpable,
）︾ˇ︾（ Tenderness：(-)
∕ ﹨ Rebunding pain：(-)
∕ x ﹨ Palpable mass：(-)
▏ ｜
▏ ∕︶﹨ ｜
●Back：Knocking pain:(-) Radiation pain:(-), No compression sore wound.

●Extremities：right side hemiplegia,
one chronic ulcer over left foot (about 8cmx6cmx0.5cm in size),
Movable on left side, Edema(-) Deformity(-)
Tenderness noted near the pressure sore wound.
■ 入院診斷
1.massive pleural effusion, left side,
R/O parapneumonic empyema or malignant effusion (higher CA-199 level).
2.DM type2, with medication
3.old CVA, right hemiplegia
4.Renal function impairment
■ 主要計劃
Pre-operation evaluation and SICU care.
Arrange VATS as soon as possible.
NPO, bed rest with Intravenous fluid supplement before operation.
Intravenous Antibiotic medication to control Infection.
Wound care with standard method of Wet-dressing for foot chronic ulcer.
Consult Nephrology Doctor for renal function impairment. Arrange
urinalysis, Urine culture, 24hr Protein/Ccr Examination.
【Pleural effusion and Thoracic Empyema】住院診療計畫
●HISTORY and PHYSICAL EXAMINATION ●Lab. EXAMINATION

└─→○Pleural effusion/Empyema←─┘ ┌Chest X-ray
┌──┘ ├Needle aspiration
│┌○Injury/trauma→→→→┐ ├Bronchoscopy
││ ↓ ├Cytologic examnation
36
││ ●Tube thoracostomy ├Sputum culture and smear
│├○Postthoracotomy↗ (Expand lung) └Skin test
││ ↗ ↓
│├○Infection: ↗ ├○Continue →●Thoracoscopy→●Emergency
└┤Pneumonia/lung abscess │ bleeding Thoracotomy
│ └→●Antibiotics ├○Clotted→→●Decoartication
│ Thoracentesis┐ │ hemothorax
├○Spontaneous │ ├○Bronchopleural→→●Operative closure
│├→●Antituberculosis │ │ fistula
│↓ drug │ ├○Serous or pus→→●Irrigation and
closure
│●Thoracoscopy and/or └┐└┐
│ Exploratory thoracotomy └→└○Chronic empyema cavity
│ ↗ ↓
├○Tumor→Drugs for pleural symphysis ├Rib resection and
drainage
│ ├Decortication
└○Thrombophlebitis/Embolus→Anticoagulants ├Thoracoplasty
血栓性靜脈炎 └Resection
醫師簽章：○○○
37
ADMISSION（小兒科）
病歷號碼:00417189
00/00/0 00:00
衛生署豐原醫院姓名:劉 00
出生日期:000000 性別:男
--------------------------------------------------------------------------------
§日期︰00/00/00 §時間︰00︰00 §醫師︰方謨德
--------------------------------------------------------------------------------
■ 主訴
cough for many days,fever since 0/00.
■ 病史
according to the statement of family,
this patient had cough for many days,
fever developed since 0/00,he was brought
to our er for help,there chest breathing
sound rale noted ,under the imression of r/o
bronchopneumonia,he admitted to our ward
for care.
■ 體檢發現
Past hitory:
(1)Birth history: N-P
(2)Vaccination: as schedule
(3)Newborn screen: normal
(4)Growth and development: normal
(5)Allergy hx: denied
(6)Previos hospitalization:
Family history: Non-contributory.
Body weight:9 kg ,Body temperature: C
General appearance:
Conscious: clear( )
HEENT:
No craniofacial dysmorphism
Conjuntiva : pale ;Sclera:not icteric
Ear drums: no
Nose:no deformity
Throat: injected
Tonsils: injected
Neck:supple ,LAP (-/- ),JVE(-/- )
Chest:
Breathing sound :coarse( + ), Wheezing ( - ), Rales( + )
Rhonchi( ++)
Symmetric expansion(+)
Retraction sign: -
Heart:
Regular heart beat, Murmur( - ) Tachycardia( - )
Abdomen:
Soft and flat , Bowel sound: normoactive
TENDERNESS ( - ) ,Rebounding pain( - )
Liver/Spleen :impalpable
Extremities:
Freely movable ,pitting edema ( - ) ,acrecyanosis( - )
SKIN:
Tugor:normal ,rash ( - )
CxR:
KUB:
** 血液學檢查 **
38
Date(Time) Blood type RH type (D
0000000(2158) A (+)
ＡｄｍｉｓｓｉｏｎＮｏｔｅ
Date(Time) RBC WBC Hb Hct Platelet
0000000(2158) 2.340 13.900 3.800 13.800 1019.000
MCV MCH MCHC N-Seg Lymph
59.200 16.400 27.700 84.000 16.000
Mono Eosin Baso\
0000000(2158) 2.180 13.700 3.500 12.700 938.000
58.200 16.000 27.500 84.000 16.000
Mono Eosin Baso
--------------------------------------------------------------------------------
** 一般生化學檢查 **
Date(Time) Ｃ反應性蛋
0000000(2158) 0.500
--------------------------------------------------------------------------------
■ 入院診斷
485 支氣管性肺炎
■ 主要計劃
1.ON PEDIATRICWARD ROUTINE
2.IV FLUID AND ELECTROLYTES
3.SUPPORTIVE CARE
主任醫師蓋章: 主治醫師蓋章:○○○ 住院醫師蓋章:○○○
39
ADMISSION（婦產科）
病歷號碼:00000000 00/00/00 00:00
衛生署豐原醫院姓名:施 00
住院序號:00000000000 床號:1310-02
出生日期 :0000000 性別 : 女
-----------------------------------------------------------------------------------------------------------------------------
§日期︰000/00/00 §時間︰00:00 §醫師︰ooo
-----------------------------------------------------------------------------------------------------------------------------
■ 主訴
Low abdominal pain for one week.
■ 病史
Past History :
1.DM :denied
2.Hypertension :denied
3.Denied other systemic disease
4.Denied surgical 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. Menopause at 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 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.
■ 體檢發現
Physical Examination :
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
40
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
(3)Palpation:tenderness and rebouding pain over right underside
palpable mass over underside
Lab Data:
Date(Time) * APTT * PT (sec * PT (INR)
00/00/00(0900) 24.0 12.2 1.24

00/00/00(0900) 4.680 9.500 10.800 34.100 308.000
72.900 23.000 31.500 80.200 12.100
Mono Eosin Baso
7.200 0.100 0.400
* 尿液檢查 **
Date(Time) PH SP.gr protein Sugar urobilinog
00/00/00(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
00/00/00(0900) Negative
--------------------------------------------------------------------------------
SMA:
Date(Time) Creatinine GOT Sugar-Ac
00/00/00(0900) 1.200 20.000 130.000
Image Fundings:
41
CXR:
Date(Time):00/00/00(1940), Chest PA
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.
--------------------------------------------------------------------------------
■ 入院診斷
620.5 卵巢、卵巢蒂或輸卵管之扭轉
789.00 腹痛
■ 主要計劃
1. Admission routine
2. Pre-OP prepare
3. Operative
4. Keep IV fluid
5. Antibiotics used
6. Wound care
7. Symptomatic treatment
主任醫師蓋章: 主治醫師蓋章:○○○ 住院醫師蓋章:
42
病歷號碼:000000 oo/oo/oo
姓名:000
住院序號:oooooooooo 床號:2207-02
出生日期:oooooo 性別:女
Admission Note
日期:oo/oo/oo 時間:oo:oo 醫師:ooo
□ 主訴
R’t knee TKR S/p and reomove prosthesis on 94-02.
□ 病史
This is 76 y/o old female was bil THR S/P and R’t TKR S/P on 93-08 with osteomyelitis not
remove implant prosthesis S/p on 94-02, regular our OPD for follow up treatment. She suffered
from soreness and claudication over R’t Knee for months. Exam :CPR:0.2(o/oo)
This time, she reviced revision TKR and admitted to our ward for further evaluation
and management.
□ 檢體發現
Pas history :
1.Systemic disease : DM(-) H/T(-)
Heart disease (-) renal disease (-)
2.Operative History : Bil THR S/P for years ago, R’t TKR S/P on 93-08 after infect and
osteomyelitis received remove prosthesis on 94-02
3.Habitual history : smoking(-)alcohol(-)betal nut chewing(-)
4.Family History : (-)
5.Allergy history : Nil
Physical examination :
Consciousness : clear (+) confused(-)stupor(-)coma(-)
Coma scale : E4 M6 V5
Vital signs : BT:36.3c HP:74/min RR:19/mim BP:158/83mmhg
Eye: 1.pupil:isocoria(+)
2.conjunctiva:not anemic(+) ;anemic(-)
3.sclera:not icteric(+)
Neck: stiff(-);supple(+)
juglar vein engorgement(-)
palable mass(-)
Chest: Symmetric expansion(+);asymmetric expansion(-)
heart sound :regular(+), irregular(-)”heart bear
murmur(-)
Abdomen: flat(+), distended(-);soft(+), guarad(-)
Bowel sound : hypo(-) normal(+) hyper(-) active
Liver/spleen
tenderness(-)
robunding tenderness (-)
palpable mass:(-)
Back: knocking pain(-);radiation pain(-)
Extremities : movable free(-);limited(+)
R’t knee old scar and contraction , poor ROM, claudication
□ 入院診斷
R’t THR S/P and remove prosthesis S/P
715.36 局部骨關節病, 小腿
□ 主要計劃
1. Prepare op on revision TKR (R’T)
2. post-op antiviotics and analgesic support
3. Ice packing x qid 15’/times
4. CD x QD (o/oo)
5. On CPM x Bid (o/oo) 43
主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：○○○

ADMISSION（骨科）
44
ADMISSION（泌尿科）
+General Data:
Name: 林 oo Admitted Ward: 1519-2
Age: 88 Chart No.: 000000
Sex: male Occupation: Nil
Marital status: married Date of admission: oo/oo/oo
Chief Complain：Acute urinary retention since this morning
Family History：non-contributory
Past History:
1.Bladder cancer s/p Transurethral resection of bladder tumor on oo/oo/oo, oo/oo/oo, oo/oo/oo
2.Benign prostatic hyperplasia s/p Transurethral resection of prostate on 00/00/00
3.Urethral stricture s/p optic urethrotomy on 00/00/00
Systemic Disease:
DM : ( - ) Heart disease : ( - )
H/T : ( - ) Renal disease : ( - )
Present Illness and physical Examination：
This 88 y/o male patient was a case of bladder cancer (Transitional cell carcinoma) s/p
Transurethral resection of bladder tumor three times in the past. He was also a victim of urethral
stricture s/p optic urethrotomy. Post op course was smooth. This time, gross hematuria had bothered
him for 1-2 months. He and his family didn’t care about it. Unfortunately, acute urinary retention
attacked since this morning, he came to our ER for help. Sonagraphy showed bladder distension.
foley catheter was indwelled but failed due to resistance at uretehra. Due to acute urinary retention
with gross hematuria, R/O recurrent bladder tumor and urethral stricture, he was admitted for further
evaluation and surgical treatment.
Personal History & Allergic History ：
Smoking ( + )
Alcohol ( - )
Betal nut chewing ( - )
No history of drug allergy
PE：
Consciousness : clear
E4.M6.V5.
T.P.R.37.1℃, 93/min, 21/min
45
B.P. 159/74mmHg
eye : isocoric
conjunctiva : not anemic
sclera : not icteric
neck : supple
jugular vein engorgement : ( - )
lymph node adenopathy : ( - )
palpable mass : ( - )
chest : symmetrical expansion
breathing sound : clear
heart : regular heart beat
abdomen : flat , soft
bowel sound : normal active
liver / spleen : no palpable
tenderness : ( - )
rebounding pain : ( - )
palpable mass : ( - )
back : knocking pain : ( - )
radiation pain : ( - )
extremities : movable free
no edema
no deformity
no tenderness
Imp: 1.R/O Transitional cell carcinoma of urinary bladder, recurrence
2.R/O urethral stricture
Plan to do：1.Admission routine & pre op evaluation
2.Arrange TUR-BT and optic urethrotomy
3.IV fluid supply
Sign: Dr.
主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：○○○
46
ADMISSION（復健科）
Name:劉 00 Chart no.548404
Sex/age:male/27 Admission date : 00-0-0
Chief complaint:
Bilateral low limbs weakness
Present illness:
This 27 year-old male was admitted via 中國醫藥大學附設醫院 ER on 00-0-0 because of
fever and acute urinary retension. Fever with bilateral legs weakness , failure to ambulation and acute
urinary retension with difficulty in urination was noted. Consciousness disturbance (E2M4V3) was
noted with hypotension (Bp:69/43). Brain CT revealed non significant change and lumbar puncture
was done which showed aseptic meningitis. Consciousness improved after antibiotic and antivirus
agent were using. However four limbs weakness were noted and upper limbs gradually recovered to
about grade 4 of muscle power, but bilateral lower limbs weakness, loss of sensory and urinary
retention still present. Brain MRI on 4/5 revealed medulla and T12 lesion and encephalitis, transverse
myelitis were impressed.
Tracheostomy tube was removed on 5/14. Sinus tachycardia was noted at the same time, due to
his condition was relative stable, he was transferred to rehabilitation ward for training.
Now bilateral low limbs weakness, left side is more severe than right side were persisted, unable
to walk independent was noted. So he was admitted to our ward for further evaluation and
management.
Past history:
1. No other systemic disease
2. allergy : nil
3. smoking : +
4. alcohol drinking : social
5. occupation : 工程師
Physical exam:
General appearance : a well developed male without ill looking
Consciousness : alert , GCS:E4M6V5
HEENT : no skull deformity
Conjunctiva : no anemic sclera : no icteric
throat : no swelling , no injected
urine : no incontinence
stool : no incontinence
anal sensation : + anal tone : +
anal reflex : +
FINCTIONAL STATUS :
Rolling : +/+
Sitting balance : poor/fair
Standing up : moderate assistant,
Standing balance : poor
Ambulation : with quadricanes with moderate assistance
Transfer : with moderate assist
ADL :
Feeding : independent
Light hygiene : independent
Dressing/undressing : independent
Heavy hygiene : moderate assistance
FIM
SELF CARE :
A. eating : 6 B. grooming : 6 C. bathing : .
D. dressing upper body : 4 E. dressing low body : 3
47
F. toilet : 3
Sphincter control
G. bladder management : 4 H. bowel management : 3
Transfer
I. bed , chair, wheelchair : 4 J. toilet : 3
K. tub shower : 3
Locomotion
L. walk/wheelchair : 4 M. stairs : 1
Communication
N. comprehension : 7 O. expression : 7
Social cognition
P. social interaction : 7 Q. problem solving : 7
R. memory : 7
Diagnose : 1. aseptic meningitis

2. transverse myelitis
主任醫師蓋章: 主治醫師蓋章: 住院醫師蓋章:
48
ADMISSION（耳鼻喉科）
行政院衛生署豐原醫院病歷摘要 (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
000
病歷號碼:0000000000 00/00/00 00:00
0136010010 衛署豐原醫院
衛生署豐原醫院 0000000000
姓名:000 00 年 00 月 00 日 00000000
(6)轉入醫院 (7)地址 000000000
住院序號:00000000000 床號:3305- (8)流水編號
(9)入院日期 00 年 00 月 00 日胸腔科出生日期:0000000 性別:男
病床號碼 2517
年月日病床號
(10)轉科(床) --------------------------------------------------------------------------------------------
年月日 - 病床號
§日期︰000/00/00 §時間︰00︰00 §醫師︰000
(11)出院日期 00 年 00 月 00 日住院天數計日
--------------------------------------------------------------------------------------------
(12) 入院 ■1.主訴 Hemoptysis, R/O lung cancer, R/O lung abscess
Sleep
2. Benign disorder,snoring and sleep
prostate hyperplasia s/p disorder off and
transureteral on for of
resection a long time.
prostate
出院 ■ 病史
1. Lung abscess, RLL
According to the statements of the patient and his family,
2. heBenign prostate
compained sorehyperplasia
throat , sleeps/p disorder
transureteral resection
and snoring offof prostate
(13)主訴 . Intermittent
and on forcough
a longwith bloody
time.He eversputum
came for one month
to LMD for help,but in vain.
(14)病史 Then he came to our hospital for help.After examination,
This 81 y/o male patient was an exsmoker (1PPD for 50 years and has quit for 4 years).
He wasenlarged tonsils,
relative wellprolpse
in theuvula
pastand narrow
except oropharynx
benign prostatewere noted. s/p transureteral
hyperplasia
Under the impression of chronic tonsillitis and upper airway anomaly,
resection ofheprostate on 00/00/00
was admitted andtreatment
for surgical 00/00/00. andThen theevaluation.
further symptom of dysuria was
improved.
■ 體檢發現
This time, he says he occasionally coughed up about 10 cc of blood streak sputum twice
CONSCIOUS:CLEAR
a day in recent one month. The symptoms spontaneous stopped within 2-3minutes.
GCS:E4V5M6
Besides,
VITAL sometimes
SIGNS:BP: dullness
119 /localized
87 MMHG anteriorTPR:
chest36.9/68
pain when
/20 he deeply inspiration was
notedINTEGUMENT:NORMAL
in recent one week. He denies SKINfever,
TURGOR,NO EDEMA,NO
alcohol drinking, ERUPTION,NO
any known exposure to TB,
PETECHIAE
recent pneumonia history, recent hoarseness, familial history of lung cancer, symptoms of
NO ECCHYMOSIS,NO
bleeding problems, e.g., bleeding gums, CLUBBINGfrequentFINGER
bruising, difficulty stopping bleeding,
exertional dyspnea, recent weight loss or melena. Therefore, he came to our hospital and
was HEENT:CONJUNCTIVA:NOT
evaluated in the OPD. CXR revealed PALEa cavitary mass without satellite lesion over right
SCLERA:NOT ICTERIC
lower lung NOfield.
PTOSIS Under the impression of hemoptysis, R/O lung cancer or lung abscess. He
was admitted
ISCORICto ourPUPILS
ward for further
WITH evaluation
NORMAL and treatment.
LIGHT REFLEX
Throughout the course
NORMAL VISUAL ACUITY of the disease, there was no skin lesion, consciousness change,
fever or TONSILS:ENLARGED
dyspnea, but cough with bloody sputum was noted.
(15)體檢 NECK:SUPPLE,NO LAP,NO JVE,THYROID GLAND:NOT ENLARGED
Past History:
發現 4. DM (-), HTN (-), COPDSYMMETRIC
CHEST:BILATERAL (-), Asthma (-), EXPANSION
TB (-), CV disease (-), CVA (-)
BREATH SOUND:CLEAR
5. Other major systemic disease: denied
PERCUSSION:RESONCE
6. Surgical history: benign
HEART:REGULAR prostate
HEART hyperplasia
BEAT,NO MURMURs/p transureteral resection of prostate on
00/00/00 and 00/00/00
ABDOMINEN:FLAT,NO SCAR,NO SUPERFICIAL VEIN ENGORGEMENT
PersonalACTIVE HistoryBOWEL & Allergic SOUND History :
,NO BRUITS
4. Alcohol SOFT,NO TENDERNESS,NORMAL
consumption: denied LIVER AND SPLEEN SPAN
EXTREMITIES:NO
5. Smoking: 1PPD for 50 EDEMA,NO
years and has DEFORMITY,FREELY
quit for 4 years MOVABLE
■ 入院診斷
6. Allergy: denied drugs or food allergy history
780.53 嗜睡伴有睡眠呼吸中止
Family474 History:
慢性扁桃腺炎 Non-contributory
Review478 of鼻甲肥大system:
11.■Systemic:
主要計劃fever (-), BW loss (-), easy-fatigibility (-), change of appetite (-), dizziness(-)
1.Complete
12. Skin: petechiaepre-op examination
(-), purpura (-), skin rash (-), itching (-)
體 13. 2.Arrange
HEENT: operation
blurred for
vision evaluation
(-), strabismus (-), ocular pain (-), ear ache (-), otorrhea (-),
檢 hearing loss (-), tinnitus (-), vertigo (-), nasal stuffiness (-), nasal discharge (-), nasal
發 bleeding (-), gum bleeding (-), glossitis (-), sorethroat (-)
現 14. Cardiovascular: exertional chest tightness (-), PND (-), orthopnea (-), syncope (-),
palpitation (-), intermittent claudication (-)
15. Respiratory: dyspnea (-), cough (+), chest pain (+), hemoptysis (+)
主任醫師蓋章：
16. GI: anorexia (-), nausea 主治醫師蓋章：○○○(-), vomiting (-), dysphagia (-), heart burn (-), acid
住院醫師蓋章：○○○
regurgitation (-), abdominal fullness (-), hunger pain (-), midnight pain (-), constipation
(-), diarrhea (-), melena (-), change of bowel habit (-), small caliberofstool (-), tenesmus
49
(-), flatulence (-)
17. Urogenital: flank pain (-), hematuria (-), urinary frequency (-), urgency (-), dysuria (-),
hesitancy (-), small stream of urine (-), impotance (-), nocturia (-), polyuria (-),
oligouria (-)
18. Musculoskeltal: bone pain (-), arthragia (-), muscleache (-), weakness (-)
19. Metabolic: heat intolerance (-), cold intolerance (-), thirsty (-)
20. Nervous: numbness (-), paresis/plegia (-)
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: (+/+)
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 (-)
體 (4) Auscultation: wheezing (-), rhonchi (+) over right upper lung field, crackle (-)
檢 Heart:
發 (5) Inspection: no visible PMI
現
(6) Palpation: thrill (-), heave: (-)
(7) Percussion: normal shape
(8) Auscultation: RHB, no murmur
Abdomen:
(4) Inspection: flat shape, superficial vein engorgement (-), OP scar (-)
(5) Auscultation: Normal active bowel sound, gastric succussion (-), bruits (-)
(6) 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: (-)
50
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 Nil
期及方法
(包括手術 Nil
發現)
(17)住院治 After admission, A serious of examinations including (1) Chest CT scan: necrosing tissue
療經過 with infectious infiltration over RLL. (2) Sputum cytology: negative for malignancy. (3)
Sputum acid fast stain: not found (4) tumor markers were within normal range were
preferred the diagnosis of lung 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)檢查記一般檢查(如:尿液糞便.血液.生化.細菌……..之檢查)

錄 **血液學檢查**
1. CBC: (Date:00/00/00)
WBC: 6.4 K/UL (DC: 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)
51
(20)放射線 1. CXR (Date: 00/00/00): tortous aorta with calcified wall and normal heart size,
報告 infiltration of LUL and RLL
2. Chest CT scan (Date: 00/00/00): infectious process at superior segment of right lower
lobe is mostly likely, minimal amount of pleural effusion over right lung
(21)病理報 Sputum cytology (Date:00/00/00, 28 and 29): negative for malignancy
告(包括病
理發現)
(22)其他 Nil
(23)出院時改門診治療
情況
(24)出院指處置名稱次劑量單位服法天總量單位
示 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
52
行政院衛生署豐原醫院病歷摘要 (外科)
0136010010 行政院衛生署豐原醫院江 00 00000000 00/00/00 00000000
(6)轉入醫院 00000000 醫院 (7)地址 00000000000000 (8)流水編號
(9)入院日期 00 年 00 月 00 日外科病床號碼
(10)轉科(床) 年月日科病床號年月日科病床號
(11)出院日期 00 年 00 月 00 日住院天數計 00 日
(12) 入 1.massive pleural effusion, left side,
診院 R/O parapneumonic empyema or malignant effusion (higher CA-199 level).
2.DM type2, with medication
斷 3.old CVA, right hemiplegia
出 1.massive parapneumonic empyema, left side.
院 2.DM type2, with medication
3.old CVA, right hemiplegia
(13)主訴 Massive left-side pleural effusion noted on chest X-ray image for more
than 10days.
(14)病史
This 74y/o man with a past history of old CVA, chronic respiratory
failure with depending on ventilator suffered from left side
pleural effusion since 00/00/00 and Chest CT examination
was performed on00/00/00. Massive pleural effusion of left thoracic
cavity was noted and chest tapping pleural fluid study showed bloody
appearance and tumor survey showed Higher CA-199 level(32.34). Under
the impression of parapneumonic pleural effusion, he was referred to
our hospital on 00/00/00 for thoracic endoscopic examination.
Tracing his relational history, he was sent to 衛生署○○醫院 on
00/00/00 due to SOB and vomiting with coffee-ground material. After RLL
pulmonary infiltration was noted with CXR and respiratory failure,
endotracheal intubation was performed and transferred to ICU for
intensive care under the impression of aspiration pneumonia with upper
GI bleeding. Owing to prolonged ventilator support, tracheostomy was
performed on 00/00/00. Tumor survey was also performed on 00/00/00,
AFP=2.05, CEA=2.51, PSA=0.605, CA-199=32.34.
【Past History of Major Systemic Diseases】

Old CVA with right hemiplegia
Gastric cardia ulcer with antral gastritis. (PES:00/00/00)
DM, type 2 with regular control.
Hypertension with CHF,
Renal diseases: High Cr level noted:2.5(00/00/00), 3(00/00/00),
2.8(00/00/00), 3.5(00/00/00),4.4(00/00/00). U/A showed Proteinuria.
Chronic Anemia:Hb level between 8.5-10.7g/dl
Asthma(-), COPD(-), Liver Diseases(-),
Allergy(-)
【Personal Habitude】smoking(-), alcoholic drinking(-),
【 Family History 】DM(-), CVA(-), HTN(-), Tumor(-) All denied.
【Operative History】Tracheostomy on 00/00/00
Debridement on 00/00/00
(15)體檢發現【The Major Findings of Physical Examination On Admission 】

●Consciousness：alert, but sometimes confused.
●Coma Scale：E(4)M(6)V(T)
●General appearance: chronic ill-looking. Weakness. Right hemiplegia.
skin turgor: dry and loose. No tremor. Muscle power: all 4+
●Vital Signs：BP=175/83mmHg, PR=69/min, RR=12/min, BT=36℃
●BH=about 170cm, BW=about 55kg.
●HEENT：
53
◇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. tracheostomy tube in place without discharge and depended on
ventilator(Pressure support mode)
●Chest：
no using of accessory-respiratory muscle,
symmetric expansion, intermittent shortness of breathing,
︵ no subcutaneous emphysema, no open wound of chest wall.
∕ ﹨
｛`︷'｝Heart sound：regular rhythm without murmur. No click, No
thrill.
╰─╯ Breathing sound：rales over left side. No wheezing.
╴ ∕ ﹨＿ ●Abdomen：
∕ ＼〒／ ﹨ Soft, not guarded. Scaphoid in appearance.
﹨Bowel Sound：normal active.
﹨ ⊙ ⊙∕ Liver/Spleen:nonpalpable,
）︾ˇ︾（ Tenderness：(-)
∕ ﹨ Rebunding pain：(-)
∕ x ﹨ Palpable mass：(-)
▏ ｜
▏ ∕︶﹨ ｜
●Back：Knocking pain:(-) Radiation pain:(-), No compression sore

wound.
●Extremities：right side hemiplegia,
one chronic ulcer over left foot (about 8cmx6cmx0.5cm in size),
Movable on left side, Edema(-) Deformity(-)
Tenderness noted near the pressure sore wound.
(16) 手術日期 VATS, Decortication of pleura and chest tube drainage on 00/00/00.
及方法(包括手
術發現)
(17) 住院治療 1.On tracheostomy with ventilator support
經過 2.Respiratory care
3.Appropriate antibiotics
4.Chest tube drainage
5.Analgesic agent
6.Wound care
7.Control underlying disease.
(18)合併症 NIL
(19) 一般檢查(如:尿液.糞便.血液.生化.細菌......之檢查)
檢 ** 特殊檢驗 **
Date(Time) Urine-Osmo Na
查 00/00/00(1038) 315 28.2/L
---------------------------------------------------------------------
紀 ** 尿液檢查 **
錄 00/00/00(1038) 5.5 1.018 +++(>=300) +(0.25) 0.1
54
- - - ++ ++
RBC WBC Bacteria
20-25 30-35 +
00/00/00(1038) 6.5 1.020 +++(>=300) +-(0.1) 0.1
- - - +++ +++
RBC WBC Epithelial Bacteria Granular
50-55 55-60 - + 2-3
----------------------------------------------------------------------
Date(Time) Hb
00/00/00(1038) 12.300
Date(Time) Hb Blood type RH type (D
00/00/00(1038) 9.400 A +
00/00/00(1038) 27.8 14.1 1.45
00/00/00(1038) 3.550 5.200 9.900 29.700 195.000
83.800 27.900 33.300 66.100 17.000
Mono Eosin Baso
7.000 9.300 0.600
----------------------------------------------------------------------
Date(Time) * Creatini * TP
00/00/00(1038) 32.4 155
Date(Time) Creatinine
00/00/00(1038) 4.300
Date(Time) BUN Creatinine Na K Albumin
00/00/00(1038) 67.100 4.600 136.000 5.000 2.900
Date(Time) Creatinine K
00/00/00(1038) 4.200 4.800
Date(Time) BUN Creatinine Na K GOT
00/00/00(1038) 53.100 4.400 133.000 4.800 24.000
GPT
31.000
---------------------------------------------------------------------
Date(Time):00/00/00(2041), 檢體:Urine(已用抗生素)
Microorganisms Growth Microorganism Growth
isolated issolated
*1.Staphylo.aureus >100000 4.
cfu/ 5.
2. 6.
3.
Antibiotics Antibiotics
Susceptibility 1 2 3 4 5 6 Susceptibility 1 2 3 4 5
6
Amikacin OFLOXACIN
Gentamycin R Ciprofloxacin
Gentamycin 120 mg Levofloxacin
Penicillin G R Pefloxacin
Oxacillin R Baktar(SXT) R
Ampicillin 10 Clindamycin
Ampi/Sulb Erythromycin
Ceftazidime Tazobactam
Cephalothin Vancomycin S
Ceftizoxim Piperacillin
55
Ceftriaxone Imipenem
Cefuroxime Fusidic acid S
Cefmetazole Tetracycline
Cefepime Metronidazole
★ S:Susceptible, M:Moderately Susceptible, I:Intermediate, R:Resistant
--------------------------------------------------------------------
Date(Time):00/00/00(1643), Blood culture (血液): No growth for 7 day.
---------------------------------------------------------------
Date(Time):00/00/00(0956), Sputum culure
Microorganisms isolated Growth Microorganism Growth
issolated
*1.Pseudomo.aeruginosa +++ 4.
2. 5.
3. 6.
Antibiotics Antibiotics
Susceptibility 1 2 3 4 5 6 Susceptibility 1 2 3 4 5
6
Amikacin S OFLOXACIN
Gentamycin S Ciprofloxacin R
Gentamycin 120 mg Levofloxacin R
Penicillin G Pefloxacin
Oxacillin Baktar(SXT)
Ampicillin 10 Clindamycin
Ampi/Sulb Erythromycin
Ceftazidime S Tazobactam S
Cephalothin Vancomycin
Ceftizoxim Piperacillin S
Ceftriaxone Imipenem S
Cefuroxime Fusidic acid
Cefmetazole Tetracycline
Cefepime S Metronidazole
★ S:Susceptible, M:Moderately Susceptible, I:Intermediate, R:Resistant
---------------------------------------------------------------------
Date(Time):00/00/00(1206), Acid fast stain: 檢體:Sputum (痰液) Not
found
---------------------------------------------------------------------
Date(Time):00/00/00(0956), Sputum Gram stain: 檢體:Sputum (痰液)
Gram stain: WBC> 25/LPF, EP< 25/LPF, Gram(+) Bacilli +, Gram(-) Bacilli
+, 此檢體接受
----------------------------------------------------------------------
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):00/00/00(0947), Portable CXR
告 The chest showed tortuous aorta with normal heart size. There was
increased soft tissue density over the right para-tracheal region.
Engorged brachiocephalic vein or other etiology was suspected. There
was right apical pleural thickening. Increased lung markings of both
lungs was noted. Infiltrations of both lungs was found, in stationary
as compared with the
film dated on 00/00/00. No definite abnormal bone fracture or lesion of
the clavicles and ribs was seen. There were tracheostomy tube and
nasogastric tube in place.
-----------------------------------------------------------------------
Date(Time):00/00/00(0928), Portable CXR
The chest showed tortuous aorta with normal heart size. There was
56
nasogastric tube in place. A chest tube was in place to left upper
chest.
-----------------------------------------------------------------------
chest.
----------------------------------------------------------------------
lungs was noted. Infiltrations of both lungs was found, in progression
at RUL as compared
ith the film dated on 00/00/00. No definite abnormal bone fracture or
lesion of the clavicles and ribs was seen. There were tracheostomy tube
and nasogastric tube in place. A chest tube was in place to left upper
chest.
----------------------------------------------------------------------
lungs was noted. Infiltrations of both lungs was found, in statioanry
chest.
---------------------------------------------------------------------
lungs was noted. Infiltrations of both lungs was found, in progression
at right lung as
compared with the film dated 4 hours ago. No definite abnormal bone
fracture or lesion of the clavicles and ribs was seen. There were
tracheostomy tube and nasogastric tube in place.
A chest tube was in place to left upper chest.
----------------------------------------------------------------------
lungs was noted. Infiltrations of both lungs was found. No definite
abnormal bone fracture or lesion of the clavicles and ribs was seen.
There were tracheostomy tube and nasogastric tube in place.
(21)病理報告 Date(Time):00/00/00(1131),第四級外科, 特殊染色第,特殊染色第,一般病理檢
57
Addendum on 00/00/00
1.Lung, plaura, left, VATS and excision, inflamed granulation tissue
with neutrophilic and histiocytic infiltrate.
2.Special stain, PAS and Acid-fast, not contributory. The specimen
submitted consists of 3 tissue fragments measuring up to 0.8x0.2x0.1 cm
in size fixed in formalin.
Grossly, they are brown and soft. All for section. Jar 0
The microscopic findings are described in the diagnostic column.
(22)其他通知:000/00/00 00:00 一般會診皮膚科回覆:00/00/00 00:00 李○
○
Dear Dr 陳主任:
This 74 Y/O Male Victim Of Thoracic Empyema S/P VATS Chest Tube
Drainage And Unasyn + Amikacin Was Examinated & Hx Reviewed. Sudden
Onset Of Rash Developed Over Chest In Recent 2 Days.
Pe - Wide-Spreading Pinkish Erythematous Mottled Confluent Plaques Of
Chest & Upper Abdomen, R't Flank. Less Over R't Med Thigh But Sparing
Of Pubic Area & Diaper Area, Arms
Dx - Contact Dermatitis, R/O Due To Detergent B-I Sol'n
Suggest - Keep Good Hygiene. Cool Water Tapping Prn
Then Rinderon Va Cream Top Bid For Rash Of Trunk
Calamine Lotion Top Prn For Rash
Oral Antihistamine, As Your Prescription
Observation Thanks!
通知:00/00/00 00:00 一般會診腎臟科回覆:0940623 09:58 劉○○
Dear Dr. History Was Reviewed Patient Was Examined. ARF Is Favored.
Please 1.Arrange Abdominal Sono 2.Collect 24 Hr Urine For Ccr And Daily
Urine Protein
2.Prevent Nephrotoxic Agents. 3.F/U Bun/Cr Na / K /Ca Abg Regularly. I
Will Follow Up This Patient. Thanks.
(23)出院情況 ■轉院
出院指示 TRANSFER TO ○○醫院
主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：
58
行政院衛生署豐原醫院病歷摘要 (小兒科)
0136010010 行政院衛生署豐原醫院 000 000000000 00/00/00 00000000
(6)轉入醫院 (7)地址 000000000 (8)流水編號
(9)入院日期 00 年 0 月 00 日小兒科病床號碼
(11)出院日期 00 年 00 月 00 日住院天數計日
(12) 入 485 BRONCHOPNEUMONIA
診院
出 485 BRONCHOPNEUMONIA, ORGANISM UNSPECIFIED
斷院 343.0 DIPLEGIC INFANTILE CEREBRAL PALSY
(13)主訴 cough for many days,fever since 0/00.
(14)病史 according to the statement of family, this patient had cough for many days, fever
developed since0/00,he was brought to our er for help, there chest breathing sound rale
noted ,under the imression of r/o bronchopneumonia, he admitted to our ward for care.
(15)體檢發現 Past hitory:

(1) Birth history: N-P
(2) Vaccination: as schedule
(3) Newborn screen: normal
(4) Growth and development: normal
(5) Allergy hx: denied
(6) Previos hospitalization:
Family history: Non-contributory.
Body weight: 9 kg , Body temperature: C
General appearance:
Conscious: clear( )
HEENT:
No craniofacial dysmorphism
Conjuntiva : pale ;Sclera:not icteric
Ear drums: no
Nose: no deformity
Throat: injected
Tonsils: injected
Neck: supple ,LAP (-/- ),JVE(-/- )
Chest:
Breathing sound :coarse( + ), Wheezing ( - ), Rales( + )
Rhonchi( ++)
Symmetric expansion(+)
Retraction sign: -
Heart:
Regular heart beat, Murmur( - ) Tachycardia( - )
Abdomen:
Soft and flat , Bowel sound: normoactive
TENDERNESS ( - ) ,Rebounding pain( - )
Liver/Spleen :I mpalpable
Extremities:
Freely movable , pitting edema ( - ) ,acrecyanosis( - )
SKIN:
Tugor: normal ,rash ( - )
CxR:
59
KUB:
(16) 手術日期 NIL
及方法(包括手
術發現)
(17) 住院治療 After admission, IVF and Cefa was given. Fever and cough subsided gradually. Because
經過 his condition was stable, he was dischared with OPD F/U.
(18)合併症 NIL
60
檢 ** 尿液檢查 **
查 0000000(1634) 7.0 1.001 - - 0.1
紀 - - - - -
RBC WBC Epithelial
錄 0-1 0-1 0-1
---------------------------------------------------------------------------------
** 糞便檢查 **
Date(Time) OB Consistenc Color Digestion Mucus
0000000(1634)(-) FORMED BROWN MODERATE -
PUS Blood Gas WBC ASCARIS
- - - - -
HOOKWORM TRICHURIS CLONORCHIS ENTEROBISV RBC
- - - - -
---------------------------------------------------------------------------------
0000000(1634) 3.530 9.200 8.600 26.500 705.000
75.100 24.300 32.300 77.100 13.300
Mono Eosin Baso
8.200 1.400 0.000
Date(Time) Blood type RH type (D

0000000(1634) A (+)
RBC WBC Hb Hct Platelet

2.340 13.900 3.800 13.800 1019.000
59.200 16.400 27.700 84.000 16.000
Mono Eosin Baso

0000000(1634) 2.180 13.700 3.500 12.700 938.000
58.200 16.000 27.500 84.000 16.000
Mono Eosin Baso
-------------------------------------------------------------------------------
Date(Time) Ｃ反應性蛋
000000(2158) 0.500
--------------------------------------------------------------------------------
NIL
61
(20)放射線 Date(Time):0000000(1857), Chest PA
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 lungs was noted.
-------------------------------------------------------------------------------
(21)病理報告 NIL
(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

Afuco 100mg 1/ 5 粒 QIPO 2 8/ 5 粒
INOLIN 3mg 1/ 6 粒 QIPO 2 4/ 3 粒
Antisemin 4mg(Periatin) 1/ 6 粒 QIPO 2 4/ 3 粒
Ambroxol(Musco)30mg 1/ 5 粒 QIPO 2 8/ 5 粒
Baclon 10mg(Solofen) 1/ 2 粒 TIPC 2 3/ 1 粒
62
行政院衛生署豐原醫院病歷摘要 (婦產科)
0136010010 行政院衛生署豐原醫院 ooo 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
(12) 入 620.5 TORSION OF OVARY, OVARIAN PEDICLE OR FALLOPIAN TUB
診院 789.00 ABDOMINAL PAIN
斷出 620.5 TORSION OF OVARY, OVARIAN PEDICLE OR FALLOPIAN TUB

院 789.00 ABDOMINAL PAIN
s/p laparoscope right salpingo-oophorectomy
(13)主訴 Low abdominal pain for one week.
(14)病史 Past History : 1.DM :denied
2.Hypertension :denied 3.Denied other
systemic disease
4.Denied surgical 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
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.
63
(15)體檢發現 Physical Examination :
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
(3)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 : 1. Right ovary torsion
術發現) 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 00/00/00

經過 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
64
(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)
** 尿液檢查 ** Date(Time) PH
SP.gr protein Sugar urobilinog
000000(0900) 7.0 1.036 +(30MG) - 0.1
+ +- - - -
RBC WBC Epithelial Bacteria Amorphous
0-1 3-5 3-5 + +
Date(Time) preg-EIA
0000000(0900) Negative
------------------------------------------------------------------------
** 血液學檢查 ** Date(Time) * APTT
* PT (sec * PT (INR) 000000(0900) 24.0 12.2 1.24
000000(0900) 4.680 9.500 10.800 34.100 308.000
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
----------------------------------------------------------------------------
TVS sonography showed: Right ovary cystic tumor 10cm
R/O torsion
(20)放射線報 Date(Time):000000(1940), Chest PA

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.
65
(21)病理報告 Date(Time):000000(1419), 第四級外科, 一般病理檢 Adnexa,
( 包括病理發 right, salpingoophorectomy, benign ovarian serous cyst with torsion manifested as
現) massive hemorrhagic infarction and adjacent foci of 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
(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
66
行政院衛生署豐原醫院病歷摘要 (骨科)
0136010010 衛署豐原醫院 ooo oooooooooo oo 年 oo 月 o 日 ooooooo
(6)轉入醫院 (7)地址 (8)流水編號
(9)入院日期 oo 年 o 月 oo 日骨科 1308 – 05 病床號碼
(10)轉科(床) oo 年 o 月 oo 日骨科 2207 - 02 病床號年月日 - 病床號
(11)出院日期 oo 年 o 月 o 日住院天數計 o 日
(12) 入 R ’t TKR S/P and infection
院
出 R ’t TKR S/P
院 Hypotension
Hypovolemia
Insomnia
(13)主訴 R’ t knee TKR S/P and reomove prosthesis on 94-02.
(14)病史 This is 76 y/o old female was bil THR S/P and R’ t TKR S/P on 93-08 with
osteomyelitis note remove implant prosthesis S/P on 94-02 , regular our OPD for
follow up treatment. She suffered from soreness and claudication over R’ t knee
for months. Exam: CPR:0.2 (o/oo)
This time, she reviced revision TKR and admitted to our ward for further
evaluation and management.
(15)體檢發現 Past history:
1. Systemic disease: DM (-) H/T(-)
Heart disease (-) renal disease (-)
2. Operative History: Bil THR S/P for years ago ,R ’t TKR S/P on 93-08 after infect
and osteomyelitis received remove prosthesis on 94-02
3. Habitual history: smoking (-) alcohol (-) betal nut chewing (-)
4. Family history: (-)
5. Allergy history: Nil
Physical examination :
Consciousness: clear (+) confused (-) stupor (-) coma (-)
Coma scale :E4 M6 V5
Vital signs: BT: 36.3c HP: 74/min RR: 19/mim BP: 158/83mmhg
Eye: 1.pupil: isocoria (+)
2.conjunctiva:not anemic (+) ;anemic(-)
3.sclera: not icteric (+)
Neck:stiff (-) ; supple (+)
Juglar vein engorgement (-)
Lymph node adenopathy (-)
Palable mass (-)
Chest: Symmetric expansion (+) ; asymmetric expansion (-)
Heart sound: regular (+) ,irregular (-) “ heart beat murmur (-)
Breathing sound: clear (+)
Abdomen: flat (+), distended (-); soft (+), guarad (-)
Bowel sound: hypo (-) normal (+) hyper (-) active
Liver/spleen
Tenderness (-)
Robunding tenderness (-)
Extremities: movable free (-); limited (+)
R’t knee old scar and contraction ,poor ROM, claudication
(16)手術日期 00 / 00 / 00 64202B 人工全膝關節再置換
及方法(包括手
術發現)
67
(17)住院治療 00/00/00 Admitted and pre-op care
經過 00/00/00 Op day and transfusion PRBC 4U
Iv fluid support
Post-op antibiotics and analgesic support
00/00/00 CD x QD
00/00/00 CPM x Bid
00/00/00 Remove stiches
MBD
(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**
Date (Time) Hb
(1018) 11.900
Date (Time) Hb
(1018) 12.200
Date (Time) Blood type RH type (D)
(1018) AB (+)
Date (Time) *APTT *PT (sec) *PT (INR)
(1018) 24.7 11.2 1.13
Date (Time) RBC WBC Hb Hct Platelet
(1018) 3.970 3.800 11.800 35.100 243.000
MCV MCH MCHC
88.200 29.600 33.600
**一般生化學檢查**
Date (Time) BUN Creatinine
(1018) 20.800 1.100
Date (Time) BUN Creatinine GOT GPT Bilirubin
(1018) 23.200 1.000 34.000 23.000 0.100
Sugar-Ac
114.000
Date (Time): (1445) , Pus(from: w , Pus(from w
體檢:Wound
No aerobic pathogens was isolated
No anaerobic pathogens was isolated
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) (0833), Knee (R ‘t)
告 The right knee showed post operative status with total knee replacement with two
drainage tubes in place.
Date(Time) (0933), Chest PA

The chest showed tortuous aorta with calcified wall and normal heart size.
Increased lung markings of both lungs was noted.
No definite abnormal bone fracture or lesion of the clavicles and ribs was seen.
There was osteoporosis of the skeleton.
(21)病理報告 Nil
(包括病理發
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
Lonine (Etodolac) 200mg 1/1 粒 TIPC 7 21/ 1 粒
68
Shuane 200mg (Dorsiflex) 1/1 粒 TIPC 7 21/ 1 粒
PROATATHLIN-A 250mg 1/1 粒 QAPH 7 28/ 1 粒
A.M.D 1/1 粒 TIPC 7 21/ 1 粒
69
行政院衛生署豐原醫院病歷摘要 (泌尿科)
0136010010 行政院衛生署豐原醫院林 00 00000000 00/00/00 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 日泌尿外科 1519 - 02 病床號碼
(11)出院日期 00 年 00 月 00 日住院天數計 4 日
(12) 入 1.R/O Tranistional cell carcinoma of urinary bladder, recurrence
診院 2.R/O urethral stricture
斷出院 1.Transitional cell carcinoma of urinary bladder, recurrence
2.Urethral stricture
(13)主訴 Acute urinary retention since this morning
(14)病史 This 88 y/o male
Transurethral patientofwas
resection a casetumor
bladder of bladder cancerin(Transitional
three times the past. He cell
was carcinoma) s/pof
also a victim
urethral stricture s/p optic urethrotomy. Post op course was smooth. This time, gross
hematuria had bothered him for 1-2 months. He and his family didn’t care about it.
Unfortunately, acute urinary retention attacked since this morning, he came to our ER
for help. Sonagraphy showed bladder distension. foley catheter was indwelled but failed
due to resistance at uretehra. Due to acute urinary retention with gross hematuria, R/O
recurrent bladder tumor and urethral stricture, he was admitted for further evaluation and
surgical treatment.
(15)體檢發現 BP:159/74mmHg BT:37.1℃

HR:93/min RR:21/min
conscious:clear conjunctiva:not anemic
eye:isocoric heart:regular heat beat
brething sound:clear
(16) 手術日期 Transurethral resection of bladder tumor and urethral sounding on 00/00

及方法(包括手
術發現) 1. bulbous urethra stricture
21 Fr scope can't be inserted
sounding to 28Fr (segment: about 0.5cm)
2. huge papillary tumor at left post wall
huge diverticular at left post wall
near LUO, with many papillary
tumor within it
papillary tumor at right side
trigone near bladder neck
huge tumor at Ant. wall and bladder neck
TUR-BT was done
then on 20 Fr 3 way silicon foley
and continuous N/S irrigation
70
(17)
經過住院治療 1. TUR-BT and urethral sounding were performed on 00/00
2. post op course was smooth
3. continue N/S bladder irrigation for 1 day the urine became not red.
4. manual
voiding. N/S bladder irrigation on 00/00 less clot wash out the removed foley,try
5. since condition stable
voiding smooth
so MBD on 00/00
(18)合併症 Nil
檢 ** 血液學檢查 **
查 Date(Time) * APTT * PT (sec * PT (INR)
0000000(1543) 30.6 11.8 1.20
紀 Date(Time) RBC WBC Hb Hct Platelet
錄 0000000(1543) 4.990 12.600 10.700 33.500 294.000
67.100 21.400 31.800 92.400 5.900
Mono Eosin Baso
1.700 0.000 0.000
----------------------------------------------------------------------------
Date(Time) BUN Creatinine Na K Cl
0000000(1543) 9.300 1.200 135.000 3.300 101.000
GOT GPT Sugar-Ac
19.000 11.000 118.000
----------------------------------------------------------------------------
Nil
(20) 放射線 as report
報告
(21)病理報告 Patho:pending
71
(22)其他 Nil
出院指示
72
行政院衛生署豐原醫院病歷摘要 (復健科)
0136010010 行政院衛生署豐原醫院王劉 00 00000000 00/00/00 00000000
(6)轉入醫院 (7)地址 0000000000 (8)流水編號
(9)入院日期 00 年 00 月 00 日復健科 3302 病床號碼
(10)轉科(床) 00 年 00 月 00 日復健科病床號年月日科病床號
(11)出院日期 00 年 00 月 00 日住院天數計 16 日
(12) 入 850.9 CONCUSSION,UNSPECIFIED
診院 436 ACUTE,BUT ILL-DEFINED,CEREBROVASCULAR DISEASE
斷出院 INTRACRANIAL HEMORRHAGE S/P WITH LEFT HEMIPLEGIA
L4-4 SPONDYLOLISTHESIS
SHOULDER HAND SYNDROME,LEFT SIDE
(13)主訴 Left side of extremity weakness and motor functional impairment.
(14)病史 According to statement of the patient’s family, past history has UGI bleeding
And gout.
She suffered
our ER from traffic
for hele,Brain CTaccident
revealedand consciouness
right loss
basal ganglia on 00-0-0.thsn
hemorrhage,so she was sent to
emergent
craniotomy and removal hematoma was done,and admitted to ICU care,no complication
was found at acute stage, after condition and rehabilitation program.
Now left limbs weakness and motor functional dependent were persisted. So she was
admitted.
(15)體檢發現 General appearance: no acut ill-looking.

Conscious: clear
HEENT:Isocoric pupils with normal light reflex
EOM: free
Central type Lt side fascial palsy
Normal gag reflex
Tongue deviated to the Lt side
No anemic conjuntiva, no icteric sclera
Ncek :Supple, no neck lymphadenopathy,no
Jugular vein engorgement.
Chest:Symmetric expansion, clear breath sound,
No rales, no wheezing, regaular heart
Beat without murmur.
Abdomen:Soft and flat, no tenderness, no hepatosplenomegaly, no palpable mass.
Extremities and Back: no deformity, no edema, no pressure sore.
Rehabilitation condition:
Cognition function: normal JOMAC
Speech: Fluent speech. Naming: good.
Comprehension: good, repetition: good
Swallowing:
Tongue ROM and stength: good
Swalloinf reflex(+)
Chocking(-)
Sphincter:Bladder: no incontinence
Bowel: no incontience
Motor status:LUE proximal/distal:II-III/II
LLE:II-III
Muscle tone: no hypertonous
DTR: Increased over LT ankle jerk
Sensory: hypesthesia over the left side
Proprioceptive sensation: poor over Lt side
Hemineglect: hemineglect to dual stimulation
Hemianopsia:(-)
FIM:
Self Care: Eat: 5
Grooming: 4
Dressing upper/lower body:2/1
Toilet/Bath: 1/1
Transfer: To bed: 3 To toilet/tub: 1/1
Sphincter: Bladder/Bowel: 7/7
Locomotion: Level/Stairs: 1/1
Communication: comperehension/expression: 7/7
Social activity: 6
Problem solving: 5
Memory: 5
(16) 手術日期 NIL
及方法(包括手
術發現)
(17)
經過住院治療 1. ARRANGE OT, PT TRAINING
2. ARRANGE IF, LEFT SHOULDER; MF ,LEFT MEDIAL THIGH
(18)合併症 nil
73
(19) 一般檢查(如:尿液.糞便.血液.生化.細菌……之檢查)
檢 nil
查特殊檢查(如:超音波.內視鏡.呼吸.循環.神經.泌尿.耳鼻喉.眼……之檢查)
nil
紀
錄
(20)放射線報
告 Nil
(21)病理報告 Nil
(22)其他 Nil
(23)出院情況 IN NO ACUTE DISTRESS

(24)出院指示 KEEP OP , OT TRAINING
TRIANGLE SLING WAS USED FOR LEFT SHOULDER
74
行政院衛生署豐原醫院病歷摘要 (耳鼻喉科)
0136010010 衛署豐原醫陳 oo 000000000 oo 年 oo 月 o 日 0000000000
(6)轉入醫院 (7)地址 0000000000 (8)流水編號
(9)入院日期 oo 年 o 月 oo 日耳鼻喉科 305 – 病床號碼
(10)轉科(床) oo 年 o 月 oo 日病床號年月日 - 病床號
(11)出院日期 oo 年 o 月 o 日住院天數計 o 日
(12) 入院 474 CHRONIC TONSILLITIS
780.53 HYPERSOMNIA WITH SLEEP APNEAHYPOVLEMIA
478.0 C H R
出院 474 CHRONIC TONSILLITIS
780.53 HYPERSOMNIA WITH SLEEP APNEAHYPOVLEMIA
478.0 CHR
(13)主訴 Sleep disorder,snoring and sore throat off and on for a long time.
(14)病史 According to the statements of the patient and his family. He
complained sore throat,sleep disorder and snoring off and on for a
long time.He ever came to LMD for help,but in vain. Then he came to
our hospital for help.After examination, enlarged tonsils ,prolong
uvula and narrow oropharynx were noted. Under the impression of
chronic tonsillitis and upper airway anomaly, he was admtted for surgical
treatment and further evaluation.
(15)體檢發 CONSCIOUS:CLEAR GCS:E4V5M6
現 VITAL SIGNS:BP:119 /87 MMHG TPR:36.9 / 68 /20
INTEGUMENT:NORMAL SKIN TURGOR,NO EDEMA,NO ERUPTION,NO
PETECHIAE NO ECCHYMOSIS,NO CLUBBING FINGER
HEENT:CONJUNCTIVA:NOT PALE
SCLERA:NOT ICTERIC NO PTOSIS
ISCORIC PUPILS WITH NORMAL LIGHT REFLEX
NORMAL VISUAL ACUITY
TONSILS:ENLARGED
NECK:SUPPLE,NO LAP,NO JVE,THYROID GLAND:NOT ENLARGED
C EXPANSION BREATH SOUND:CLEAR
PERCUSSION:RESONCE
HEART:REGULAR HEART BEAT,NO MURMUR
ABDOMINEN:FLAT,NO SCAR,NO SUPERFICIAL VEIN ENGORGEMENT
ACTIVE BOWEL SOUND ,NO BRUITS
SOFT,NO TENDERNESS,NORMAL LIVER AND SPLEEN SPAN
EXTREMITIES:NO EDEMA,NO DEFORMITY,FREELY MOVABLE
(16)手術日 00/00/00 UPPP LASER

期及方法手術前診斷: chronic tonsillitis with upper airway anomaly
(包括手術
發現) CHR
手術後診斷: chronic tonsillitis with upper airway anomaly
CHR
手術術式: Uvulopalatopharyngoplasty (UPPP)
CO2 LASER
1.Under GE, the patient was into supine position with neck hyperextended,the oral
carvity was sterilized first.
2.The incision line was made over the ant pillas then dissection was made till the
75
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 enlarged uvula was shortened with preserved the muscular layer , then the
ant. and post pillas was sutured tog ether with the depth of oropharynx about
1.5cm.
6.The blood loss was minimal.
7.The patient was sent to POR with a stable condition.
(17)住院治 1.Antibiotic treatment 2.Cold compression

療經過 3.Local treatment 4.Oral hygiene
(18)合併症 Nil
(19)檢查記一般檢查(如:尿液.糞便.血液.生化.細菌......之檢查)
錄 **血液學檢查**
0000000(1039) 24.5 10.8 1.09
0000000(1039) 4.990 8.100 15.400 44.400 220.000
88.800 30.800 34.600 61.100 26.300
Mono Eosin Baso
7.900 4.200 0.500
--------------------------------------------------------------------------------
** 一般生化學檢查 ** Date(Time)
Creatinine Na K Cl GPT 0000000(1039) 1.000
141.000 4.100 103.000 20.000
Sugar-Ac
108.000
--------------------------------------------------------------------------------
Date(Time):0000000(0848), Chest PA
The chest showed
tortuous aorta with normal heart size. Increased lung markings
of both lungs was noted. No definite abnormal bone fracture
or lesion of the clavicles and ribs was seen.
--------------------------------------------------------------------------------
(20)放射線 Date(Time):0000000(0848), Chest PA

報告 The chest showed tortuous aorta with normal heart size. Increased
lung markings of both lungs was noted. No definite abnormal
bone fracture or lesion of the clavicles and ribs was seen.
--------------------------------------------------------------------------------
76
(21)病理報 Date(Time):0000000(1610), 第三級外科, 一般病理檢
告(包括病 Oral cavity, uvula, UPPP, focal reactive lymphoid hyperplasia and
理發現) interstitial hemorrhage.
The specimen submitted consists of 4 tissue fragments measuring up to 1.2 x
1.1 x 0.5 cm in size fixed in formalin.
Grossly, they are brown and soft.
All for section. Jar 0
The microscopic findings
are described in the diagnostic column.
--------------------------------------------------------------------------------
(22)其他 NIL
(23)出院時 ■改門診治療
情況
(24)出院指處----------置-----------名----------稱次劑量單位服法天總---量單位
示 A.M.D 1/ 1 粒 TIPC 7 21/ 1 粒
Ketoprofen(Sepronin) 50mg 1/ 1 粒 TIPC 7 21/ 1 粒 Mucora
60mg 1/ 1 粒 TIPC 7 21/ 1 粒
NAKACEF 250mg 1/ 1 粒 TIPC 7 21/ 1 粒
Cough mixture c.c 10/ 1 cc TIPC 7 360/ 1 cc
77
外科手術記錄 (Operation Note)
姓名: ○○○ 性別: 男年齡: 50 歲第 6A 室床床
病歷號碼 ○○○○
日期及時間: 00 年 00 月 00 日
術者:○○○ 助手 ○○○
麻醉: GA
診斷手術前: CA OD DESCENDING COLON WITH TOTAL OBSTRUCTION
手術後: DITTO
手術術式: Subtotal colectomy ileorectal anastomosis
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
78
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 Ex p Lap was done from 10 cm avobe umbilicus to pubic area 10 belowed 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 th lt uerter.
6The 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 , Rt 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 etrminal ileum over 5 cm from ileocecal valves , distal transection was over 10 cm
distal to tumor .
8: the whole specimen was removed smoothly, Then, end to end anastomosis with tao layers by hand
sewn was done smoothly/ Check bleeding and a 13 mmJenson-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.
Doctor sign: ___○○○____
79
耳鼻喉手術記錄
病歷號：000000 姓名：000 性別:男
手術前診斷: chronic tonsillitis with upper airway anomaly
手術後診斷: chronic tonsillitis with upper airway anomaly
手術術式: Uvulopalatopharyngoplasty (UPPP)
1.Under GE, the patient was into supine position with neck hyperextended,the oral carvity was
sterilized first.
2.The incision line was made over the ant pillas 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 enlarged uvula was shortened with preserved the muscular layer , then the ant. and post
pillas was sutured tog ether with the depth of oropharynx about 1.5cm.
6.The blood loss was minimal.
7.The patient was sent to POR with a stable condition.
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婦產科手術記錄
姓名: 000 性別: 女年齡: 13 - 床病歷號碼: 000000
日期及時間: 00 年 00 月 00 日 00 時 00 分至 00 時 00 分
手術者: 000 助手: 000
麻醉: G.A
診斷:
手術前: R’t ovary cyst with torsion & necrosis
手術後: Ditto
手術術式: Laparoscopic salpingooophorectomy R’t , side

1. The patient was on supine 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 safty, CO2 was pumping into peritoneum till the intrabdominal
pressure reached 15 mmHg.
3. Insert the troca and video laparoscope, viewing whole pelvic organ.
4. Operative & finding:
(1) R’t ovary torsion with necrosis 10*8*7 cm
(2) L’t ovary with normal appearance.
(3) Uterine myoma 2*2 cm over post fundal region.
(4) Blood in cul-de-sac about 100 ml 圖示以助了解
5. Checked bleeding, then closed the wound.
6. patient stood the whole procedure well.
圖示以助了解
81
骨科手術記錄
Name:000 Ward:1622-01
Sex: F
Age: 74
Chart Number: 000000
Date: 00/00/00
Preoperative Diagnosis: L’t femoral intertrochanteric fracture
Postoperative Diagnosis: L’t femoral intertrochanteric fracture
Anesthesia: SA
Surgeon: 000
Assistant(s): 000
Operation Performed: ORIF+DHS
Blood Loss: 100ml
Operative findings:
Transverse fx of intertrochanteric-shaft area with complete displacement was noted.
Operative procedures:
1. P’t onsupine position under anesthesia
2. Disinfect with alcohol-betadine and drape
3. Lateral skin incision of the L’t thigh from the greater trochanter along the femoral shaft about 10 cm
4. Dissect the soft tissue and approach the greater trochanter
5. Insert guide pin at about 2 cm below the greater trochanter to appropriate position under C-arm
6. Ream and insert lag screw into exact position checked under C-arm
7. Insert plate and lock screws
8. Lock the compression screw
9. Irrigate and check bleeding
10. Close wound in layers and dress it
11. Send patient to POR
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泌尿科手術記錄
姓名：塗 00 性別：女年齡：00 病歷號碼：000000
日期及時間 00 年 00 月 00 日
術者：000, 000, 000.
麻醉：GA
手術前診斷：Right renal abscess s/p Rt PCN
手術後診斷：ditto
手術術式：1.Right nephrectomy, including adrenalectomy
OP finding:1. Pus discharge and old blood clots accumumated within the
Gerota’s fascia.
2. Easy touch bleeding with severe adhesion over the operative
field.
Anesthesia: GE by Dr 000
OP procedure： Under general anesthesia, patient was placed on Lt lateral decubitus

position and slight flexion the table. The operative field was prepared and draped as usual
sterile manner. Incision was made along the 12th rib and partial 12th rib was removed after
meticulous hemostasis. The muscle layer was divided with electrocautery and entering the
retroperitoneal cavity. The peritoneal cavity was difficult to swept medially due to severe
adhesion. Iatrogenic perforation of the peritoneum was noted during dissection and repaired
with mersilk suture. Dissection was initiated from the superior part of the Gerota’s fascia by
blunt ligation. Then the posterior part of the Gerota’s fascia was divided from the psoas
muscle. The ureter was found, divided and ligated with 2-O silk. Then dissection was
performed to divide the peritoneum medially, partial laceration was noted during dissection
was noted and repaired with mersilk immediately. The gonadal vein was identified, divided
and ligated with 3-O silk. The renal vein was identified by tracing the inferior vena cava,
divided and looped it. The renal artery was found posterior to the renal vein, divided and
ligated with 1-O silk, the renal vein was ligated with the same manner. Easy touch bleeding
was noted over the operative field. The operative field was irrigation with warm N/S. Two
CWV drains were left after every possible bleeder was checked. The wound was closed with
1-O vicryl and 3-O nylon. Patient tolerated the whole procedure well and sent to ICU under
stable condition.
Estimated blood loss: 1300cc. Blood transfusion with 4U PRBC, 4U WB and 2U FFP.
83
肆、行政院衛生署豐原醫院病歷管理規章
一、行政院衛生署豐原醫院病歷委員會設置要點
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：本會置委員七至九人，由院長就有關人員中指派兼任，並以副院長為主任委員。
第四條：本會委員任期為一年，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
主任委員陳俊列副院長
委員詹清旭病歷室主任
委員吳淑娟復健科主任
委員李昇平泌尿科主任
委員林正修主治醫師
委員吳建廷外科主任
委員陳景山婦產科主任
委員江俊士胸腔科醫師
幹事何桂瑩辦事員
任期：96 年 1 月 1 日－97 年 12 月 31 日
84
二、行政院衛生署豐原醫院病歷記錄品質審查及獎懲作業要點
一、開會所需準備工作須知
(一) 每三個月選一天各委員大都能出席之日期，且利用中午時間開會。
(二) 發開會通知單。
(三) 至總務室申請使用會議室
(四) 申購便當
(五) 將所審查之病歷，分為外、內科系病歷置於會議桌上。
二、會議討論事項
(一) 有關本院置於病歷內的表格(包括檢查報告單)，或新增、修改之表格，都需經病歷管理委員
會通過後方可使用。
(二) 有關於病歷書寫或任何作業流程，醫院各人員對於病歷的溝通問題，皆可提出提案討論。
(三) 對於醫師書寫病歷內容，給予質之審查包括住院病歷、門診初診病歷、急初診病歷、麻醉科
及放射線科等。
(四) 病歷質之審查作業要點：依病歷審查要點辦理。
1. 將所審查之病歷分為內、外科。
2. 內科系之委員審查外科病歷，外科系之委員審查內科病歷。
3. 審查分數基本為 100 分，各委員依審查表之項目，給予適量之加減分。
4. 每張審查表有主治醫師及住院醫師分數。
5. 若分數高於 90 分者由第二位審查委員審查。
6. 所審查之分數登記於質之分數表。
(五) 病歷質之審查及提案討論之事前準備工作須知
1. 質之審查表分住院、急診、門診初診、住院中病歷審查。
2. 採抽樣方式抽調醫師該月完成之病歷。
(1) 住院審查：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。
(2) 急診審查：抽調每位醫師一本急診病歷，填寫審查表。
(3) 初、複診門診病歷審查：抽調每位醫師初診患者之病歷填寫審查表。
(4) 住院中病歷審查：
4.1 共聘請 9 位醫師為住院病歷審查委員，內科系 5 位、位科系 4 位
4.1.1 內科系為鍾碧菁醫師、劉曉慧醫師、陳葆莉醫師、邱振豐醫師、林鴻慶醫師
4.1.2 外科系為李永恆主任、許俊正主任、林昱君醫師、游朝慶醫師
4.2 每位醫師依責之病房，每月各審 60 本病歷，40 本為本科系，20 本為跨科系
4.2.1 審查委員一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，於次月由住院流程團隊報告結果，病歷室將統計結果
陳閱
3. 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。
4. 影印提案所提出之資料、表格。
5. 將討論之事項，會後通知有關之單位。
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) 依質之審查之統計名次，取前 3 名，於醫務會議頒獎
(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
住院病歷書寫及紀錄品質（質）
由病歷管理委員會提供資料
1.每 2 個月審一次(審雙月)
2.分數滿分為 100 分
3.分數高於 90 分交叉審查
4.獎勵方式
4.1 每次以分數超過 90 分以上之主治醫師前 5 名、住院醫師前 3 名上網公告及醫務會議中報告。
4.2 獎勵以分數高於 90 分取名次給予獎勵。
4.2.1 總平均成績(高於 90 分)於醫務會議表揚，頒發等值獎品。
主治醫師 5 名住院醫師 3 名
第一名 2000 元 2000 元
第二名 1500 元 1500 元
第三名 1000 元 1000 元
85
第四名 500 元
第五名 500 元
5.懲罰方式
5.1 分數低於 80 分者全部上網公告需加油名單
5.2 醫會議報告需加油名單
86
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、每月 8 日、18 日及 28 日上網公佈醫師未完成排行榜。
六、依照未完成項目逐項審查，並列印未完成單夾於病歷上。
行政院衛生署豐原醫院
【修改】病歷未完成病歷維護作業
病歷號碼：_ _ _ _ _ _ 住院日期：_ _ _ _ _ _
醫師： __ __ __ 出院日期：_ _ _ _ _ _
 通知日期： _ _ _ _ _ _  備註： ﹝ 1﹞ 放棄 應完成日：_ _ _ _ _ _
實際完成天數：_ _ _ _ _ _ □預期天數：_ _ _ _ _ _登入日期：_ _ _ _
_ _
未完成項目
============================================================================
============
＊如逾期未完成者，每日每本 01 病歷摘要〈一〉
02 病歷摘要〈二〉 03 Admission
04 Progressive 05 Operation record
06 Discharge order 07 出院診斷單張
08 醫療明細審查表 09 Consultation sheet
10 手術同意書 11 麻醉同意書
12 CHRONIC Diserse 13 轉介函覆單
14 Other：
==========================================================================
行政院衛生署豐原醫院頁數：
0001
醫師未完成病歷通知單日期：
93/xx/xx
◎醫師：XX XX ~ XX XX ◎通知日期：93 XX XX ~ 93 XX XX 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
87
七、出院病歷書寫獎懲辦法
1 獎懲辦法如下：
1.1 5 日(含日歷日)內完成：主治醫師、住院醫師每本各 100 點，兩者皆完成才有獎勵。
1.2 出院日 6-7 日內完成：不罰不扣。
1.3 超過 8 日者(含日歷日)：每日每本罰 10 元採個別罰扣。
1.4 獎勵每月最高不超過 10000 點，罰扣最高不超過 12000 點。
1.5 當月逾期病歷於次月底前若不完成，依實際金額罰扣。
1.6 獎勵及罰扣金額依之前方式由獎勵金(除外)加點或罰扣。
1.7 次月月底前由病歷室出院病歷審查人員提出獎懲名單。
2 出院病歷由原 72 小時內送回病歷室改為 24 小時內送回(含日歷日) 。
2.1 星期五、六、星期日之出院病歷於星期一上午前送回病歷室。
88
四、行政院衛生署豐原醫院病歷借閱管理規則
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，佰每次不得超過廿份，並於三日內歸
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、病患由開業醫師轉介到院診治，於出院或診療完畢時，得應開業醫師之要求由院方填寫病
歷摘要一份，經醫師簽章後交患者，以便患者能在開業醫師之診所、醫院繼續治療或追蹤。
九、借閱病歷不得折角或污損。
十、借閱病歷除為醫療診斷需要，不得轉借或出示他人。
十一、病歷借閱完畢，應交還病歷室經管人員，並將其入庫。
十二、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。
行政院衛生署豐原醫院借閱單
日期：年月日
病歷號碼；姓名：
借閱人：代碼；單位碼：
89
五、行政院衛生署豐原醫院病歷摘要、影本發給要點
行政院衛生署豐原醫院病歷複製本申請流程
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、基本費用二百元(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）自申請日起三日至十四（請詳閱流程圖背面說明）
日完成後，以電話通知前來領取，並填寫領具。
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行政院衛生署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：基本費用二百元(含 10 張影本)，第 11 張起病歷影印每張五元。
(四) 申請當日請先至掛號櫃檯繳費(二百元)，領取當日視影印
張數再補收費用。
(五) 自申請日起三至十四日（請詳閱申請書背面說明）完成
後，以電話通知前來領取，並填寫領具。
※(六)請填寫以下資料（若委託書已載明，不需填寫）
病歷影本用途：
影印範圍：
□ １部分(請註明科別、期間)：科別：
　　　　　　　　　　　　　　期間：　　
□ ２全部
　申請人：
法定代理人：
受委託人：
　聯絡電話及行動電話：
申請日期　　　年　　　　月　　　　日
依台中縣衛生局規定「病歷複製本之時限規範」辦理
一、檢查檢驗報告複製本、英文病歷摘要工作天為三天。
二、全本病歷複製本、門急診病歷複製本工作天三至十四天。若領取病歷複製本時，因路途遙
遠或不克前來，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。
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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：
(一) 保險公司(如南山人壽、國華人壽、中國人壽、郵局…….等)
1. 函詢不用收文
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「行政院衛生署豐原醫院」
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)若住院醫師填填，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.查詢費用繳交掛號室入該填寫醫師之勞收。
(6)寄出方式有二：
a.傳真：將摘要表傳真給保險公司，收據用掛號寄出。
b.病歷摘要表影印一份，將正本加蓋關防連同收據用限時掛號寄出，影印本存查。
c.寄出前按保險公司登記案件，以利統計。
d.將病歷摘要表，同意書或要保書及敬會單訂好存查。
(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：
(7)查詢病歷號及調病歷。
(8)調出之病歷需登記以利追蹤。
(9)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。
(10) 病歷將醫師回復內容以公文方式函復。
(11) 影印所需之病歷資料。
(12) 函稿並陳(需陳核病歷室主任、秘書、副院長、院長)。
(13) 若為勞保局查詢，查詢費用 1000 元。
函稿並陳後，先敬會總務室開立收據。
發文至勞保局後，勞保局再寄 1000 元查詢費，給本院核銷。
收到查詢費後，除敬總務室出納，需加會計室。
(14) 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
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
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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. 稅捐稽徵肌揪稅捐徵法第三十條規定，為調查課稅資料，認為有必要要求有關醫療機構提病歷
文件時，應醫療機構在第衛生局辦理。
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
茲保證本人恪遵保密要求，無論在職、調職或離職後，對職務
上所獲悉之任何有關病患病情資料，除法律規定及業務要求外，倘
有違犯情事，願負法律責任。
具結人
職稱：
姓名：
身分證字號：
94
中華民國年月日
95
柒、疑似性侵害暨家暴病歷處理
1. 疑似性侵害之病歷、應另外存放保管並在病歷做註記。
2. 疑似家暴病歷應在病歷上做註記。
3. 疑似性侵害暨家暴病歷處理之病歷、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）
4. 疑似性侵害暨家暴病歷處理之病歷、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
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捌、附錄
一、行政院衛生署豐原醫院病歷審查表（量的審查）
行政院衛生署豐原醫院
【修改】病歷未完成病歷維護作業
病歷號碼：_ _ _ _ _ _ 住院日期：_ _ _ _ _ _
醫師： __ __ __ 出院日期：_ _ _ _ _ _
 通知日期： _ _ _ _ _ _  備註： ﹝ 1﹞ 放棄 應完成日：_ _ _ _ _ _
實際完成天數：_ _ _ _ _ _ □預期天數：_ _ _ _ _ _登入日期：_ _ _ _
_ _
未完成項目
===========================================================================
=============
＊如逾期未完成者，每日每本 01 病歷摘要〈一〉
02 病歷摘要〈二〉 03 Admission
04 Progressive 05 Operation record
06 Discharge order 07 出院診斷單張
08 醫療明細審查表 09 Consultation sheet
10 手術同意書 11 麻醉同意書
12 CHRONIC Diserse 13 轉介函覆單
14 過敏史請寫在鋒面病簽名 15 Other：
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行政院衛生署豐原醫院外科病歷之審查表月
病歷號碼：主治醫師：住院醫師：
審查委員：分數：分數：
1. 住院病歷封面及出院診斷單張：(8 分，每缺一項扣 2 分 )
(1)藥物過敏史及血型
(2)住出院日期及科別
(3)最後診斷及手術名稱(不得寫縮寫)
(4)主治醫師簽章，修改需有加註簽章
2.出院病歷摘要寫作(Discharge Note or Summary)：( 20 分，記載不完整、不理想等視情況扣分)
(1)入院、出院診斷(不得縮寫)
(2) 主訴(Chief Complaint)。
例如：epigastralgia and fullness,general maiaise,tea color urine for 4 days
(3) 病史(含家庭、職業、種族、過敏史及旅遊史)
(4) 治療過程。
例如：(1)藥物治療，需載明主藥劑量，用藥時間
(Tagamet mg tid pc & 400mg HS for 2 wks) 。
(2)手術(處置 )：應載明手術方式及結果；手術後切除組織病理送驗。
(5)有意義的檢查及檢驗(包括有意義的 Positive ans negative 的結果) 。
例如：(a.)roution 的檢查(驗)：EKG，CHEST-PA，CBC 等。
(b.)依病情需要所做的生化檢查：內視鏡，超音波等。
(6)出院時狀況(Status On Discharge)
(7)對病人出院後的指示。
例如：載明病患出院後應轉至那一科門診繼續追蹤治療，而不只寫 O.P.D.　 Follow
Up。
__________ _________ (8)醫師完整的簽章。
3.入院紀錄 (Admission Note )：(15 分)
(1)住院醫師之 Admission not 主治醫師至少改 5 個地方(2 分)
(2) Chief Complaint (1 分)
(3) Present Illness (3 分)
(4) Past History (1 分)
(5) Personal History (1 分)
(6) Family History (1 分)
(7) Physicial Examination (2 分)
(8) Impression (2 分)
(9) 醫師完整簽章 (1 分)
__________ _________ (10)主要計畫( plan to do) (1 分)
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4.病程紀錄(Progress Note )：( 22 分，每項依情況扣分，扣至０分為止)
(1)Title 若寫成 Progressive or Progression 或無 Title 扣 2 分。
(2)應將病情及治療情形，依 POMR 詳為記載，若記載過於簡單，不理想等視情
況扣分。
(3)轉科記錄(Accept Note ，２分)
(4)7 日以上需有主治醫師親自寫 Weekly summary，未寫扣 10 分
(5)每次記錄均有完整的醫師簽名（２分）。
(6)是否按日記載(ICU 要有記載時間)，（２分）
__________ _________ (7)住院醫師之病程紀錄每 3 次至少有主治醫師以紅筆改一個地方
未寫扣 10 分
5.手術記錄(Operation Note)；(１ 5 分)，每項若不完整或不理想，扣１分，扣至０分為止)
(1)手術所花費時間。
(2)手術名稱、方式（應註明本手術是屬選擇性開刀或緊張開刀　　Elective
Surgery or Emergency Surgery ）。
(3)手術前、後診斷。
(4)手術醫師及助手姓名。
(5)手術過程（必要時應繪圖說明）。
(6)應繪圖(影像)說明。
(7)手術 Finding。
(8)麻醉方式。
(9)手術取出之器官或切除部份。
(10)有無引流管，若有則應註明型式、放置位置。
(11)手術期間病人情況。
(12)手術後病人情況。
　　　　　　　　　　 (13)手術後切除組織病理送驗（５分）
6.醫囑單（１ 0 分）
__________
_________ (1)電子醫囑單及醫囑清單每張均有醫師簽名或蓋章(4 分)
(2)抗生素用法是否適當；如使用數量，有無做過敏性試驗，細菌培養，感受性試
驗等。（２分）
(3) Prednisolone 等類用藥是否適當及其他藥物之適應性。（２分）
(4) 若有藥物過敏應註記病歷封面，並有醫師簽章。（２分）
7.綜合意見；(１ 0 分，每項依情況扣分，扣至０分為止)
(1)入院診療說明書，醫師簽章(無說明書或簽章扣 4 分)
(2)同意書醫師簽章(手術、麻醉、侵入性檢查、處置等) （3 分）
(3)TPR 表上有否記載特殊檢查、輸血、抗生素之使用及處置(3 分)
99
行政院衛生署豐原醫院內科病歷之審查表月
病歷號碼：主治醫師：住院醫師：
審查委員：分數：分數：
________
1.住院病歷封面：( 8 分，每缺一項扣 2 分 )
(1)藥物過敏史及血型
(2)住出院日期及科別
(3)最後診斷及手術名稱(不得寫縮寫)
(4)主治醫師簽章，修改需有加註簽章
2.出院病歷摘要寫作(Discharge Note or Summary)：(20 分，記載不完整、不理想想等視情況扣分)
(1)入院、出院診斷(不得縮寫)
(2) 主訴(Chief Complaint)。
例如：epigastralgia and fullness,general maiaise,tea color urine for 4 days
(3) 病史(含家庭、職業、種族、過敏史及旅遊史)
_ (4) 治療過程。
例如：(1)藥物治療，需載明主藥劑量，用藥時間
(Tagamet mg tid pc & 400mg HS for 2 wks) 。
(2)手術(處置 )：應載明手術方式及結果；手術後切除組織病理送驗。
(5)有意義的檢查及檢驗(包括有意義的 Positive ans negative 的結果) 。
例如：(a.)roution 的檢查(驗)：EKG，CHEST-PA，CBC 等。
(b.)依病情需要所做的生化檢查：內視鏡，超音波等。
(6)出院時狀況(Status On Discharge)
(7)對病人出院後的指示。
例如：載明病患出院後應轉至那一科門診繼續追蹤治療，而不只寫 O.P.D.　
Follow Up。
__________ _________ (8)醫師完整的簽章。
3.入院紀錄 (Admission Note )：( 20 分)
(1)住院醫師之 Admission not 主治醫師至少改 5 個地方(2 分)
(2) Chief Complaint (1 分)
(3) Present Illness (3 分)
(4) Past History (1 分)
(5) Personal History (1 分)
(6) Family History (1 分)
(7) Physicial Examination (2 分)
(8) Impression (2 分)
(9) 醫師完整簽章 (1 分)
__________ _________ (10)主要計畫( plan to do) (1 分)
4.病程紀錄(Progress Note )：( 32)分，每項依情況扣分，扣至０分為止)
(1)Title 若寫成 Progressive or Progression 或無 Title 扣 2 分。
(2)應將病情及治療情形，依 POMR 詳為記載，若記載過於簡單，不理想等視情
100
況扣分。
(3)轉科記錄(Accept Note ，２分)
(4)7 日以上需有主治醫師親自寫 Weekly summary，未寫扣 10 分
(5)每次記錄均有完整的醫師簽名（２分）。
(6)是否按日記載(ICU 要有記載時間)，（２分）
__________ _________ (7)住院醫師之病程紀錄每 3 次至少有主治醫師以紅筆改一個地方
未寫扣 10 分
5.醫囑單（１ 0 分）
__________ _________ (1)電子醫囑單及醫囑清單每張均有醫師簽名或蓋章(4 分)
(2)抗生素用法是否適當；如使用數量，有無做過敏性試驗，細菌培養，感受性試
驗等。（２分）
(3) Prednisolone 等類用藥是否適當及其他藥物之適應性。（２分）
(4) 若有藥物過敏應註記病歷封面，並有醫師簽章。（２分）
6.綜合意見；(１ 0 分，每項依情況扣分，扣至０分為止)
(1)入院診療說明書，醫師簽章(無說明書或簽章扣 4 分)
(2)同意書醫師簽章(手術、麻醉、侵入性檢查、處置等) （3 分）
(3)TPR 表上有否記載特殊檢查、輸血、抗生素之使用及處置(3 分)
行政院衛生署豐原醫院急診病歷品質之審查表年月
病歷號碼：
急診醫師：
審查委員： __ __ __ __ __ __ 分數__ __ __ __ __ __
101
1、急診病歷診斷：〈20 分〉
__ __ __ __ __ __ 〈1〉診斷。〈10 分〉
__ __ __ __ __ __ 〈2〉檢傷分類/離去方式。〈5 分〉
__ __ __ __ __ __ 〈3〉診治醫師簽章。〈5 分〉
2、急診病史：〈35 分〉
__ __ __ __ __ __ 〈1〉主訴。〈10 分〉
__ __ __ __ __ __ 〈2〉過去病史〈5 分〉。
__ __ __ __ __ __ 〈3〉藥物過敏，是否有註記在病歷封面並簽章〈5 分〉。
__ __ __ __ __ __ 〈4〉理學檢查〈15 分〉。
3 急診處置：〈40 分〉
《1》檢驗：
__ __ __ __ __ __ 〈a〉是否適當。〈5 分〉
__ __ __ __ __ __ 〈b〉有意義之檢驗是否詳細記載〈如 AMI 記載如 ECG 及 troponin 之結果〉。〈5
分〉
《2》藥物治療：
__ __ __ __ __ __ 〈a〉輸液之適應性。〈5 分〉
__ __ __ __ __ __ 〈b〉藥物之適應性〈是否重複、劑量是否正確〉〈10 分〉
《3》處置：
__ __ __ __ __ __ 〈a〉是否適當〈如插管、手術、會診…〉
〈5 分〉
《4》簽章：
__ __ __ __ __ __ 〈5 分〉
4、綜合意見：〈10 分〉
__ __ __ __ __ __ 〈a〉有留觀是否有紀錄。
__ __ __ __ __ __ 〈b〉會診適當性。
__ __ __ __ __ __ 〈c〉英文拼字是否正確清晰。
__ __ __ __ __ __ 〈d〉其他
行政院衛生署豐原醫院門診病歷審查表月
病歷號碼：　　　　　　　　　　　　主治醫師：　　　　　　　　　
審查委員：　　　　　　　　　分數：　　　　　　　　　
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
102
審查項目：看診日期：
１. 　　　　　　　　藥物過敏欄及血型是否填寫並簽章（初診 10 分、複診 5 分）
２. 　　　　　　 Chife Complaints（複診應有此次主訴記錄，與上次門診記載內容不能完全

相同(１０分)
３. 　　　　　　 Past History、家族史、旅遊史、職業及工作概況（初診 15、5 分）

４. 　　　　　　 Present Illness（初診１ 5 分、複診 30 分）
5. ______________ Physical Examination 包括身高、（必要的理

學檢查，重要或異常之檢查紀錄）（２０分）
6. _______________ Impression（臆斷及必要之鑑別診斷治療效果）（１０分）
７. 　　　　　　　 Management（１０分）
８. 　　　　　　　醫師簽章或蓋章（字跡清晰）（１０分）
行政院衛生署豐原醫院住院中病歷品質審查表年月
基本資料
審查醫師：黏貼處
審查項目：優可改進
1. 住院記錄完整且詳實(包括:病人主訴及現在病史、過去病史、家族史、藥物
過敏史及旅遊史、職業及工作概況、理學檢查適當並包括身高、體重等項。)
2. 是否有寫過敏史並註明日期及簽章
3. Admission note 於一天內完成
4. Progress note 依 POMR 方式書寫詳實完整
5. Progress note 應每日記載並簽名(字跡清晰)
6. 主治醫師巡診記錄詳實並有適當修改病歷內容(Admission note 至少修改 5
處; 每 3 天 Progress note 至少修改一次).
7. Weekly summery 內容簡要清楚(未超過 7 天可不寫)
8. 會診記錄回覆完成(未會診可不審)
9. TPR sheet 完整，有記錄主要檢查、重要處置(手術)及抗生素使用
10. 入院診療計劃說明書，詳實並有醫病雙方簽名
11. 手術(重要檢查)記錄完整(有圖解)，於 1 天內完成，並簽名
103
12. 手術，檢查，麻醉同意書有醫病雙方簽名並內容完整
13 電子醫囑有醫師簽章
14. 有關醫學名詞以全名書寫而不用縮寫
教學評鑑項目：
15. 第一週 progress note 中有病情解釋內容並有醫病雙方簽名
16. 第一週 Progress note 中有主治醫師病例教學記錄
17. 第二週 Progress note 中有相關醫學倫理及法律問題討論
18. 第二週 Progress note 中有相關實證醫學的討論
分數總計：
審查醫師建議：
審查項目建議事項
104
說院長批示病歷遺失原因說明遺月
行
明失
併驗：位病
政
歸報病歷
日
院
檔告歷單衛
銷，遺
案送失
生
病借署
歷閱豐
室單原
製位
作或
醫
臨人病
院
時員患病
病應姓
名歷
歷會
，同
遺
遺診失
失治請
病醫示
歷師
尋檢
單
獲齊
或有
歷怡政病病
出關單雌豐歷碼歷
現位病室室號
X
時光
應及
立各
即項
年
合檢
105

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行政院衛生署豐原醫院病歷書寫規範

FORM OF CLINICAL HISTORY

It is generally recongnized that one of the most important

The record should be sufficiently accurate and complete to

The purpose of the history is to record an intelligent,

Right Interspace Left

The description of auscultation should include rate 〈with

Note the distension and abnormal pulsation of neck veins.

11. Rectal Examination

Personal History & Allergic History :

HCC. p’t Gastric Traffic

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

主任醫師蓋章: 主治醫院蓋章:○○○ 住院醫師蓋章:○○○

【Personal Habitude】smoking(-), alcoholic drinking(-),

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

【Pleural effusion and Thoracic Empyema】住院診療計畫

●HISTORY and PHYSICAL EXAMINATION ●Lab. EXAMINATION

主任醫師蓋章: 主治醫師蓋章:○○○ 住院醫師蓋章:○○○

Personal History & Allergic History :

Marital State: Married

Date(Time) RBC WBC Hb Hct Platelet

主任醫師蓋章: 主治醫師蓋章:○○○ 住院醫師蓋章:

主任醫師蓋章： 主治醫師蓋章：○○○ 住院醫師蓋章：○○○

主任醫師蓋章： 主治醫師蓋章：○○○ 住院醫師蓋章：○○○

Diagnose : 1. aseptic meningitis

主任醫師蓋章: 主治醫師蓋章: 住院醫師蓋章:

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

(19)檢查記 一般檢查(如:尿液 糞便.血液.生化.細菌……..之檢查)

主任醫師蓋章: 主治醫師蓋章:○○○ 住院醫師蓋章:

【Past History of Major Systemic Diseases】

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

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

(15)體檢發現 Past hitory:

Date(Time) Blood type RH type (D

RBC WBC Hb Hct Platelet

Date(Time) RBC WBC Hb Hct Platelet

 The cardiac size and configuration are within normal range.

(24)出院指示 處----------置-----------名----------稱 次劑量 單位 服法 天 總---量 單位

主任醫師蓋章: 主治醫師蓋章:○○○ 住院醫師蓋章:

斷 出 620.5 TORSION OF OVARY, OVARIAN PEDICLE OR FALLOPIAN TUB

Personal History & Allergic History :

(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 00/00/00

(20)放射線報 Date(Time):000000(1940), Chest PA

The specimen submitted consists of more than 10 tissue fragments measuring up to 4 x

Grossly, they are brown and soft.

(24)出院指示 處--------置-----------名----------稱 次劑量 單位 服法 天 總---量 單位

(19)檢查記錄 一般檢查(如:尿液 糞便.血液.生化.細菌……..之檢查)

Date(Time) (0933), Chest PA

主任醫師蓋章: 主治醫師蓋章:○○○ 住院醫師蓋章:

(15)體檢發現 BP:159/74mmHg BT:37.1℃

(16) 手 術 日 期 Transurethral resection of bladder tumor and urethral sounding on 00/00

主任醫師蓋章： 主治醫師蓋章：○○○ 住院醫師蓋章：

(15)體檢發現 General appearance: no acut ill-looking.

(23)出院情況 IN NO ACUTE DISTRESS

主任醫師蓋章: 主治醫師蓋章:○○○ 住院醫師蓋章:

(16)手術日 00/00/00 UPPP LASER

(17)住院治 1.Antibiotic treatment 2.Cold compression

(20)放射線 Date(Time):0000000(0848), Chest PA

主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：○○○

主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：○○○

(19)檢查記一般檢查(如:尿液糞便.血液.生化.細菌……..之檢查)

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

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

斷出 620.5 TORSION OF OVARY, OVARIAN PEDICLE OR FALLOPIAN TUB

(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 00/00/00

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

(19)檢查記錄一般檢查(如:尿液糞便.血液.生化.細菌……..之檢查)

(16) 手術日期 Transurethral resection of bladder tumor and urethral sounding on 00/00

主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：

Doctor sign: _○○○__

主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：

主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：

主任醫師蓋章：主治醫師蓋章：○○○ 住院醫師蓋章：

醫師通知日期應完成日期姓名病歷號碼

借閱人：代碼；單位碼：

（三）收費標準(依衛生署 93.8.23 衛署醫管字第

２. 　　　　　　 Chife Complaints（複診應有此次主訴記錄，與上次門診記載內容不能完全

３. 　　　　　　 Past History、家族史、旅遊史、職業及工作概況（初診 15、5 分）