65. SOAP – 病程記錄
＃1 問題XXX
S Subjective：病人自身主觀對問題的陳述。
O Objective：醫師自病史、身體診察、與診斷
性檢驗，所搜集之客觀資料。
A Assessment: 臆斷、診斷，綜合病人主觀與
醫師客觀資料，所得到的結論。
P Plans:為解決問題，計畫將採取之步驟。
66. Post-OP – 病程記錄
S ：Pain? Swelling? Dyspnea? Sore throat? Pain
(VAS)
O ：
• Vital Signs, Oral Intake, Activity,
• Wound(Recipient/Donor), Drain, Oral hygiene
• Lab data, Image Data,
• P.E. finding
A : Dx after operation, Recovery condition?
P : Medication, Management, Instruction
75. Common Mistakes
（一）錯誤使用normal或negative
例：Physical examination was normal. (or negative).
身體檢查應該記錄發現，沒有所謂正常或＂陰性＂的。不過做了檢查後
發現一些異常的表現，相對沒有異常時，可以說身體檢查是正常。但英文應該
說，＂身體檢查沒有發現異常＂，而不是＂身體檢查（本身）正常＂。因此應
該寫為：
Physical examination revealed no abnormalities.
Results of physical examination were normal.
No abnormalities were disclosed(found, noted, detected) on physical
examination.
76. 同樣的，在一些檢查的結果是正常或無異常發現時，也常犯同樣的書寫錯誤．
例：Laboratory was negative. The biopsy was negative. The ECG was negative.
這樣應該寫為：
Laboratory tests(studies) revealed normal results.
Laboratory tests showed normal values.
Laboratory data were normal(or within normal limits)
The result of the biopsy was negative.
The pathology of the biopsy at stomach did not reveal abnormal findings.
The ECG revealed no abnormality.
77. （二）Nothing particular (N.P)或non-made的使用
直接翻譯是“無特殊之處”，但在病歷書寫實應避免寫“無特殊之處”。
應該寫出詢問出什麼，結果正常、或無發現；或是做了檢查，結果正常。
至於英文應改寫為：
nil of note, negative for, unremarkable, non-contributory
例：The family history was nothing particular.
應改為：
The family history of diseases was unremarkable (or non-contributory).
Non-made是說做了切片檢查，沒有發現不正常的（癌）細胞。
但是，英文不這麼說。
例：The biopsy was non-made. The pathology was non-made,
應改為：
The pathology did not reveal malignant cells, 或是No malignant
Cells were found in the biopsy specimen.
