Progress Note



KEY WORDS 关键词



subjective 主观, complaint 投诉, status 状态, events 事件, deterioration 恶化, interventions 干预,

objective 客观, systems 系统, vital signs 生命体征, peaks and troughs 高峰和低谷, fluids 液体, electrolytes 电解质, nutrition 营养, pulmonary 肺, cardiovascular 心血管, digestive 消化, urinary 泌尿, blood 血液, infection 感染, neurologic exam 神经系统检查, Glascow Coma Score 格拉斯哥昏迷评分, ASIA score 评分, laboratory 实验室, imaging 成像, assessment 评估, problems 问题, diagnoses 诊断, management 管理, plan 计划 (workup, procedures 程序, discharge)



TEXT / 课文



A progress note should be written at least daily on every inpatient.