前一章讲的是不同医院对语言识别结果的个性化需求,现在说一下不同的医生对于识别结果的需求。我们看下面的这个例子,例子中对很多细节都有明确的要求。
004X医院4811XX医生 规范
- 医生基本信息:4811XX--dictating doctXXXX H. LXXXXX MD-CARD 心脏科
- 常用报告模板:0001--History and Physical; 0002--Consultation; 0003--Operative Report; 0004--Discharge Summary; 0005--Pre-Op H&P; 0006--Cardiology; 0016--Procedure Note.
- 模板字体:RIS的信息: Arial Narrow 10号字; cc 开始及报告正文: Arial 10号字
- 录音特点:有口音 ,语速较慢,以testing testing testing good day this is doctor JAMES LIU dictating discharge summary/consultation/preop history and physical for PATIENT last NAME spell xx first name xx and date admission xx date of discharge xx 开始。 以please fax a copy to my office and fax a copy to Dr. xx and Contact the patient for the dentist to give him a copy of this dictation thank you 之类句子结尾,不需要写进报告.
- 报告细节:
·所有的大标题和次标题都只要大写,不要加粗,除了ALLERGIES;按照录音来确定有哪些标题.
·PE部分小标题分行写, 各个小标题之间空一行.
·分点时的提示语是new line,分段是 next paragraph,有时候会念混,要注意区分.
·医生常常念疾病名称的首字母缩写,编辑报告时需要全部展开.
·报告中病人的名字用 the patient 代替.
- 主要大标题有:
0001--History and Physical
·BRIEF HISTORY:
·HISTORY OF PRESENT ILLNESS:
·ALLERGIES:
·PAST MEDICAL HISTORY:
·CURRENT MEDICATIONS:
·FAMILY HISTORY:
·SOCIAL HISTORY:
·REVIEW OF SYSTEMS:
·PHYSICAL EXAMINATION:
·LABORATORY DATA:
·ASSESSMENT AND PLAN:
0002--Consultation 所有的大标题都要大写加下划线
·DATE OF CONSULTATION: (模板自带标题,不能删除)
·HISTORY OF PRESENT ILLNESS: (医生念BRIEF HISTORY,有时候两个都会念,这时要按照念的顺序编辑)
·ALLERGIES: 大写加粗 (内容一般为NO KNOWN DRUG ALLERGIES. 医生念的是 PAST MEDICAL HISTORY:)
·MEDICATIONS:
·ADDITIONAL MEDICAL HISTORY:
·SOCIAL HISTORY:
·FAMILY HISTORY:
·REVIEW OF SYSTEMS: (成一段编辑,小标题大写)
·PHYSICAL EXAMINATION:
·SIGNIFICANT LABORATORY:/SIGNIFICANT LABORATORY DATA:
·ASSESSMENT AND PLAN:
0003--Operative Report
·DATE OF SURGERY: (模板自带标题,不能删除)
·PREOPERATIVE DIAGNOSES:
·TITLE OF PROCEDURE: (医生念PROCEDURE)
·POSTOPERATIVE DIAGNOSES: (医生念the same,把PREOPERATIVE DIAGNOSES部分粘贴过来就可以了)
·SURGEON:
·ANESTHESIOLOGIST:
·BRIEF HISTORY:
·DESCRIPTION OF PROCEDURE: (医生念COURSE PROCEDURE)
·DIAGNOSTIC DATA: (医生不念此标题,参考内容为Postoperative chest x-ray showed no evidence of a pneumothorax or hemothorax. )
·ESTIMATED BLOOD LOSS:
·RADIATION TIME:
·ASSESSMENT AND PLAN:
0004--Discharge Summary
·DATE OF ADMISSION: (模板自带标题,不能删除)
·DATE OF DISCHARGE: (模板自带标题,不能删除)
·ADMISSION DIAGNOSES:
·DISCHARGE DIAGNOSES: (医生念the same,把ADMISSION DIAGNOSES部分粘贴过来就可以了)
·PROCEDURE:
·PHYSICIANS INVOLVED:
·BRIEF HISTORY:
·HOSPITAL COURSE: (在BRIEF HISTORY下面,医生可能不念此标题,要根据内容自己判断)
·PHYSICAL EXAMINATION UPON DISCHARGED: (小标题按照医生念的来编辑)
·SIGNIFICANT LABORATORY:
·TROPONINS:
·DISPOSITION:
·DISCHARGE MEDICATIONS:
·ACTIVITY LEVEL: (常见内容Ad lib.)
·FOLLOWUP:
0005--Pre-Op H&P
·BRIEF HISTORY: (医生念常常念REASON FOR ADMISSION: ,所以有时候也可以用这个标题)
·HISTORY OF PRESENT ILLNESS:
·DRUG ALLERGIES OR REACTIONS: (内容大写加粗,有时写作PAST MEDICAL HISTORY: ,可以根据医生念的来编辑)
·CURRENT MEDICATIONS:
·OTHER MEDICAL HISTORY:
·SOCIAL HISTORY:
·FAMILY HISTORY:
·REVIEW OF SYSTEMS: (医生会念new line分点,但是我们编辑成一段,小标题大写)
·PHYSICAL EXAMINATION:
·SIGNIFICANT LABORATORY:
·ASSESSMENT AND PLAN:
0006--Cardiology
·DATE OF PROCEDURE: (模板自带标题,不能删除)
·BRIEF HISTORY:
·INDICATIONS:
·MEASUREMENTS:
·INTERPRETATION:
·RECOMMENDATIONS:
·ASSESSMENT AND PLAN:
0016--Procedure Note.
·DATE OF PROCEDURE: (模板自带标题,不能删除)
·PREOPERATIVE DIAGNOSES:
·PROCEDURE:
·POSTOPERATIVE DIAGNOSES: (医生念the same,把PREOPERATIVE DIAGNOSES部分粘贴过来就可以了)
·PHYSICIAN:
·BRIEF HISTORY:
·DESCRIPTION OF PROCEDURE:
·ESTIMATED BLOOD LOSS:
·COMPLICATIONS:
7. REVIEW OF SYSTEMS: 的常见格式与内容:
REVIEW OF SYSTEMS: No fevers, chills, night sweats or weight changes. PSYCHOLOGICAL: Mildly anxious, no acute decompensation or intentional tremor. SKIN: No bruises or moles. HEARING: No change. VISION: No change. PULMONARY: No cough, hemoptysis, no history of tuberculosis. CARDIOVASCULAR: Please see history of present illness. GASTROINTESTINAL: No nausea and vomiting, diarrhea, constipation, flank pain, hematemesis, hematochezia. GENITOURINARY: No flank pain, dysuria, hematuria, urgency. NEUROMUSCULAR: No motor, sensory, cranial nerve deficiency.
8. PHYSICAL EXAMINATION常见格式与内容:
PHYSICAL EXAMINATION:
GENERAL: Well-developed, well-nourished 67-year-old Mandarin-speaking male in mild abdominal pain.
VITAL SIGNS: Blood pressure 111/65, pulse 70, respiratory rate 20.
SKIN: No ecchymosis, scars noted.
HEENT: The neck is supple, free range of motion. Sclerae clear, no conjunctivitis. External acoustic canal clear.
CHEST: Clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm with 1/6 systolic murmur, positive S4.
ABDOMEN: Positive bowel sounds, soft, nontender.
EXTREMITIES: No cyanosis or clubbing with 1+ edema.
LYMPHATICS: Palpable supraclavicular lymph nodes.