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轉載自 http://home.pchome.com.tw/web/ntuhderm/
台大皮膚部病歷書寫規範
• Chief complaint: the reason that patient seek for medical aid
1. Symptom, location and duration (never write your diagnosis in the chief complaint)
2. In single descriptive phrase & In patinet’s own language
• Past history: including the following points
1. Personal history of major systemic disease, including history of atopy
2. Family history, especially history of atopy
3. Occupation
4. Past and present medication (including record of adverse reaction to any medication)
5. Drug allergy, food allergy
6. Contactant
• Present illness: describe the following points
The onset, evolution, detail symptoms ( itchy, painful, etc ), associate symptoms ( fever, arthralgia, etc ), and precipitating factors of the present illness. Previous treatment and the effect of the treatment.
• Physical examination: as principles of general chart
• Cutaneous finding: The most important part in dermatological chart
1. never write your diagnosis in the cutaneous finding)
2. Use proper dermatological vocabulary to describe the lesion(s) (primary eruption, secondary eruption)
Terms for primary eruption: Macule/Patch, Papule, Nodule, Vesicle/Bulla, Pustule, Cyst, Wheal
Terms for secondary eruption: Excoriation, Erosion, Ulcer, Fissure, Abscess, Scale, Crust, Tylosis, Scar, Atrophy, Discoloration
3. Describe the character of skin lesions, such as:color, consistency, number, size, surface, shape and arrangement, distributions, patterns
shape and arrangement : Linear, Annular, Arciform, Polycyclic, Grouped, Zosteriform, Iris ( target sign)
distributions : localized, regional, generalized, total (universal), bilateral and symmetrical, sun- exposure area, seborrheic area intertriginous area, dermatomal
• Family history:
Draw the family tree
• Impression:
1. Write the possible diagnosis you take into account
2. Avoidance of abbreviation
*Remember to sign your name after completing the chart
台大皮膚部病歷書寫規範
• Chief complaint: the reason that patient seek for medical aid
1. Symptom, location and duration (never write your diagnosis in the chief complaint)
2. In single descriptive phrase & In patinet’s own language
• Past history: including the following points
1. Personal history of major systemic disease, including history of atopy
2. Family history, especially history of atopy
3. Occupation
4. Past and present medication (including record of adverse reaction to any medication)
5. Drug allergy, food allergy
6. Contactant
• Present illness: describe the following points
The onset, evolution, detail symptoms ( itchy, painful, etc ), associate symptoms ( fever, arthralgia, etc ), and precipitating factors of the present illness. Previous treatment and the effect of the treatment.
• Physical examination: as principles of general chart
• Cutaneous finding: The most important part in dermatological chart
1. never write your diagnosis in the cutaneous finding)
2. Use proper dermatological vocabulary to describe the lesion(s) (primary eruption, secondary eruption)
Terms for primary eruption: Macule/Patch, Papule, Nodule, Vesicle/Bulla, Pustule, Cyst, Wheal
Terms for secondary eruption: Excoriation, Erosion, Ulcer, Fissure, Abscess, Scale, Crust, Tylosis, Scar, Atrophy, Discoloration
3. Describe the character of skin lesions, such as:color, consistency, number, size, surface, shape and arrangement, distributions, patterns
shape and arrangement : Linear, Annular, Arciform, Polycyclic, Grouped, Zosteriform, Iris ( target sign)
distributions : localized, regional, generalized, total (universal), bilateral and symmetrical, sun- exposure area, seborrheic area intertriginous area, dermatomal
• Family history:
Draw the family tree
• Impression:
1. Write the possible diagnosis you take into account
2. Avoidance of abbreviation
*Remember to sign your name after completing the chart
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