小眼睛晶
AN EXAMPLE OF MEDICAL CASE RECORD IN ENGLISH Patient Li Hua,mate,69 years old, a retired teacher, was admitted on June 6,1989,because of palpitation for one year and becoming worse in recent 5 months. The patient was quite well until one year before May,1988, He felt slight palpitation and dyspnia during hard work, fast walk , or climbing stairs, There was swelling of legs in the evening but he felt better after having a rest. In recent 5months, palpitation and dyspnia became so serious that he could neither walk nor lie down.He had to sit up during the whole night, Sometimes he coughed with small amounts of sputum, but without blood. He had no chill, fever, chest pain or sore joints. The urinating was normal. There was nothing else abnormal in the case history review except a cured lobor pneumonia in 1949. He had no history of drug allergy. Personal history：The patient was born in Xi’an in 1923. He had been to the south of China but did not contact contaminated water. He smoked a bout 10 cigarettes daily. He got married in 1945. His wife was healthy .They had a daughter who was also healthy. His father died of stomach cancer.His mather was well. Physical Examination：T.36.8C, P. 96/min, R. 28/min, BP.23.5/13.3kPa. The patient, an old fatty man who developed well and moderately nourished, was lying in bed with a semifallous position. He looked pale and suffered from general edima. He was mentally normal and cooperative in the examination.There was no eruption, no jaundice, no purpura on the skin, and the lymphnodes were not palpable. The head, eyes, nose, ears, mouth were normal while the lips were cyanotic. The neck was soft, there was no venous engorgement. Thyroid glands were not palpable, there were no thrill or brunt. The trachea was in midline. The chest and respiratory movements were symmetrical. There was no abnormal dullness but some moist rales were heard in the base areas of the both lungs. The points of maximal impulse (PMI) were not visible but palpable in the 6thcostal interspace, 14cm form the middle line, there was no thrill. The cardiac dullness, 14cm from the middle line, there was no thrill. The cardiac dullness were as follows; Right （cm） Interspaces Left (cm) 1.5 Ⅱ 2.0 2.0 Ⅲ 4.0 3.0 Ⅳ 8.0 Ⅴ 10.0 Ⅵ 14.0 The distance from midsternal line to midclavicular line was 10cm. The heart rate was 96/min, regular. There was a grade Ⅱsoft blowinglike systolic murmurat the apex,P2>A2, but no pericardium friction sound was heard. Abdominal wall was soft without tenderness. The liver was palpable 2cm below the costal margin with slight tenderness. The spleen was not palpable and there was no shifting dull ness. The rest was normal. Impression： disease with degreeⅢ heart failure Signature ×××求采纳
佳佳13817062298
电子病历的英文缩写为EMR。
电子病历（EMR,Electronic Medical Record），也叫计算机化的病案系统或称基于计算机的病人记录（CPR,Computer-Based Patient Record）。
它是用电子设备（计算机、健康卡等）保存、管理、传输和重现的数字化的病人的医疗记录，取代手写纸张病历。它的内容包括纸张病历的所有信息。
美国国立医学研究所将定义为：EMR是基于一个特定系统的电子化病人记录， 该系统提供用户访问完整准确的数据、警示、提示和临床决策支持系统的能力。
病历是病人在医院诊断治疗全过程的原始记录，它包含有首页、病程记录、检查检验结果、医嘱、手术记录、护理记录等等。电子病历不仅指静态病历信息，还包括提供的相关服务。
是以电子化方式管理的有关个人终生健康状态和医疗保健行为的信息，涉及病人信息的采集、存储、传输、处理和利用的所有过程信息。
电子病历是随着医院计算机管理网络化、信息存储介质--光盘和IC 卡等的应用及Internet的全球化而产生的。
电子病历是信息技术和网络技术在医疗领域的必然产物，是医院病历现代化管理的必然趋势，其在临床的初步应用，极大地提高了医院的工作效率和医疗质量，但这还仅仅是电子病历应用的起步。
