Clinical Narrative Builder

1. Patient Profile & Baseline

標註 * 為核心必填，其餘留空自動省略

Age (歲) *

Sex (性別) *

Onset Verb *

Comorbidities (共病症)

+ T2DM + HTN + CKD + ESRD on HD + Active C/T + Cirrhosis

Baseline Organ Function (選填)

Preserved renal CKD stage 3

Surgical / Cardiac / Device Hx (選填)

2. Pre-admission Course & Timeline

Triggering Event / Chief Complaint *

Duration Before Admission (選填)

Despite Prior Care... (選填)

Progressive / Worsening Symptoms *

ED / Onset Date *

Admission Date (選填)

Initial Working Dx (選填)

3. Initial Evaluation & Pertinent Negatives

Key Lab Findings (選填)

Organ Dysfunction / Severity (選填)

Imaging Modality (選填)

Imaging Findings (選填)

Clinical Stability (選填)

Alert & HD stable Septic shock (on pressors)

Pertinent Negatives (選填)

+ No HF + No bleeding + No meningeal signs + No IE stigmata

4. Interventions, Microbiology & Disposition

Consulted Team (選填)

Decision / Key Procedure (選填)

Specimen Type (選填)

Result Date (選填)

Pathogen / Key Result (選填)

Confirmed Diagnosis (選填)

Destination Service (選填)

5. Antimicrobial Stewardship & Adjustment (Optional Paragraph) 獨立抗生素段落

Empiric Regimen Initiated (經驗性抗生素處方)

Pip-Tazo + Vanco Meropenem + Vanco Ceftriaxone + Azithro Cefazolin

Susceptibility / Resistance Profile (藥敏結果)

MSSA (Cefazolin-S) MRSA (Vanco MIC 1) ESBL (Carbapenem-S)

Adjustment Action (調整方向)

Targeted / Definitive Regimen (目標性處方)

IV Cefazolin IV Daptomycin Ertapenem PO Levofloxacin

Clinical Response / Planned Duration (追蹤與療程，選填)

BC cleared Afebrile & CRP ↓

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Generated Medical Narrative

點擊上方病種預設包可快速填入典型臨床骨架

* 僅核心必填欄位未填時顯示黃底提示 0 words