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●簡單說：病歷
●問題導向的記錄：要把每個問題起始 (onest) 和緩解 (resolved) 的時間記錄下來；先前確立而且不活動 (inactive) 或不須進一步處理的問題可寫 “s/p” (status post)，如 CAD (coronary arterial disease) s/p PTCA (percutaneous transluminal coronary angioplasty)；列出的問題不必要是診斷，儘量摘要、簡潔、客觀；認為是同一問題的兩個所見 (findings) 最好分開陳述；將問題依臨床的重要性逐一條列；對於你不想採取行動處理的數據 (data) 不必贅述。大家常犯的問題是病人出院時問題導向記錄 (“Problem-oriented sheet”) 還是空白的，正確作法應該是病人一住院以及隨時出現新的問題時就要記錄。
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●醫學術語縮寫標準, shorthand, 速記可用
aa, ac, ADL(activities of daily living), AFib(atrial fibrillation), AFB, AGN, AIDS, AMA(against medical advice), AM, amp, AP(anteroposterior), ARDS, ASD, ASHD, ATN(acute tubular necrosis), BBB, BP, BPH, BSO, Bx, CC(chief complaint), C/O(complained of ), C/S, CA, CAD, Cath, CBC, CGN, CHD(congenital heart disease), CHEMO, CHF, CNS, CO2, COPD, CPC, CPR, CSF, CT, CV, CVP, CXR, DC, D&C, DIC, Ditto, DJD, DM, DNR(do not resuscitate), DOA(dead on arrival), DOE(dyspnea on exertion), DPT, Dr, DVT, Dx, D5W, e.g., ELISA, ELIX(elixir), EMG, ENT, Eos(eosinophil), ER, ESRD, et, FHx, FSH, Ft, four times a day, F/U, FUO, Fx(fracture), G(gravida), GI, Gluc, gtt(s)(drops), GU, GYN, H&P(history and physical), H/D, HEENT, HIV, HLA, HSV, Hx, I&D, I&O, i.e.(that is), ICH, ICP, ICU, IDDM, im, IP jt(interphalangeal joint), IQ, ITP, IUD, iv, IVP, IVPB(intravenous piggyback), kcals, KUB, L&W(living and well), Lab, LAO(left anterior oblique), LAT, liq, LLL, LLQ, LLSB(left lower sternal border), LMD, LML(left middle lobe), LMP, LOC(loss of consciouseness), LP(lumbar puncture), Lt, LUL, LUQ, LVH(left ventricular hypertrophy), Lymph, mcg, MCL(midclavicular line), MD, mL, mm, Mono, MRI, neg, Neuro, NG tube, NIDDM, NPO, NSAID, NSR(normal sinus rhythm), OD(right eye), OS, OB-GYN, OP, OPD, Ophth, OR, ORIF, OU, Oz(ounce), PM, para(number of living children), Path, Pc, PDA, PE,PID, PKU,PMI(point of maximal impulse), PMS(premenstrual syndrome), PND(paroxysmal nocturnal dyspnea), po, post-op, PPD(purified protein derivative), pre-op, prn, pt, pta(prior to admission), PUD, PVC(premature ventricular contraction), pyelo(pyelonephritis), q-am, q1h, Qt(quart), q2h, q3h, Rt, RAD, REM(rapid eye movement), RhF(rheumatic fever), Rh Neg, Rh Pos, RHD, RLL, RLQ, RML, RN(registered nurse), R/O, ROS(review of systems), RQ(respiratory quotient), RSV, RTC(return to clinic), RUL, RUQ, RVH(right ventricular hypertrophy), Rx, SaO2, SBE(subacute bacterial endocarditis), sc, SDH, SHx(social history), SIADH, SICU, SLE, SOB, S/P(status post), Staph, Stat, Strep, STSG, Subling, Surg, T&A(tonsillectomy and adenoidectomy), Tab, TAH(total abdominal hysterectomy), TB, TIA, TKA, TMJ(temporomandibular joint), TPN, TPR, tsp(teaspoon), TURP, U, U/A, UGI, URI, Urol, UTI, UV, VSD, WBC, wks, WNL, Wt.
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