영어 해석좀 부탁드려여... 책한장반불량이거든여..(내공드려여)

영어 해석좀 부탁드려여... 책한장반불량이거든여..(내공드려여)

작성일 2003.03.11댓글 1건
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핵석좀 부탁드려여..
의학용어가 있어서 어렵겠지만 할수있는데까지 부탁드립니다.
대문자는 그냥 쓰시면 되구요..
수요일까지 부탁드려여 (저녁 10시)



Writing Interim (Progress) Notes
In an interim (Progress) note, not every category normally addressed in an initial note will be included. Use only the information obtained while reassessing the patient during treatment sessions.
If a patient's status is unchanged and the area addressed is extremely important, it is acceptable to address the area and state that it is unchanged. However, for the sake of the reader, the unchanged status should be briefly described.

EXAMPLE
(CORRECT)
Transfers :Supine ↔ sit unchanged ; still repuires mod +1 assist.
When stating that the patient's status is unchanged, it is important to make sure that all of the evaluation skills and methods available have been used. In the example above, perhaps the amount of assistance needed by the patient is unchanged, but the patient is performing the transfer more quickly (5 minutes to perform the transfer versus 10 minutes).

EXAMPLE
(CORRECT)
Transfers : Supine ↔ sit unchanged ; still requires mod + assist. but performance of transfer requites 5 min. on this date (vs. 10min. initially required). Transfer is becoming more functional.
Date used for comparison purposes can also be included. In the example above, without the comparative data, the fact that the performance of the transfer required 5 minutes would seem insignificant to the reader. The reader may not take the time to look at a previous written note in order to obtain the patient's former status, or the reader may not have the previous note available.
Information addressed in interim notes should include areas addressed in the last set of short term goals written. For example, if a goal is set for the patient to be able to roll supine →sidelying ⓡ(대문자) independently within 1 week, the patient's rolling status should be addressed under O in the next interim note.
As mentioned previously, when writing notes, it is important ot know the requirements of both the facility and the third-party payers. In some areas of the country, certain third-party payers require listing both the treatment the patient received and the patient's reaction to the treatment.
This can be listed in the O part of the note under reaction to treatment.

EXAMPLE
(CORRECT)
Reaction to Rx : Pt. received 30 min. of gait training on this date emphasizing correction of gait deviation & correction of balance deficits. Responded well to verbal cues but could not cont. to correct gait deviations s (위에줄) verbal cues

Writing Discharge Notes
The completeness of the O section of a discharge note varies greatly among practice settings. In some facilities, the discharge note is similar to an interim note and is an update of the patient's status since the last interim note was written. In other facilities, the discharge note is a more complete summary of the patient's condition upon discharge from the facility and, in format and length, is more similar to the initial note. Still other facilities use a format that summarizes the patient's condition upon beginning therapy, the general course of therapy, and the patient's status upon discharge from therapy.

Types of notes can also vary depending upon who will be reading the note. For example, a note that is forwarded to a nursing home or home health agency might be a complete summary of the patient's condition, whereas a note that will go the medical records storage when the patient is discontinued may simply update the patient's status since the last interim note was written. The home health or nursing home therapist may receive only the discharge summary from an acute or rehabilitation facility, so a more complete note is needed. For the purposes of this workbook, the discharge note is to be considered a complete summary of the patient's status upon discharge and course of therapy, and you are to address all areas of objectives data measured and / or remeasured during treatment.

Summary
The O section of the note is a very important section. It should be included in every type of note, whether it is an intial, interim, or discharge note and whether a traditional SOAP format or a SOAP format using functional outcomes as its emphases is used. The information should be organized under headings, should be written in a clear and concise manner, and should list the results of objective measurement procedures performed by the therapist.
The following worksheets give practice at the skills needed to write the O part of a note. Four worksheets are included because this portion of the note includes so many different types of information. After reviewing this chapter, working with the following worksheets. and using the answer sheets to correct the worksheets, you should be able to write the objective portion of a note easily



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Writing Interim (Progress) Notes
임시노트 작성
In an interim (Progress) note, not every category normally addressed in an initial note will be included.
임시노트에서는, 초기 노트에서 보통 지정된 모든 분야가 포함되어야 하는 것은 아니다.
Use only the information obtained while reassessing the patient during treatment sessions.
치료받는 동안에 환자를 재진단할 때 얻어진 정보만을 기입한다.
If a patient's status is unchanged and the area addressed is extremely important, it is acceptable to address the area and state that it is unchanged.
만약 환자의 상태가 변화하지 않았고 지정된 부위가 극도로 중요한 것이라면, 그 부위와 변하지 않은 환자의 상태를 지정하는 것도 가능하다.
However, for the sake of the reader, the unchanged status should be briefly described.
어쨌든, 읽는 사람을 위해서, 변화되지 않은 상태를 간략하게 묘사해야 한다.

EXAMPLE (CORRECT)
맞는 예
Transfers :Supine ↔ sit unchanged ; still repuires mod +1 assist.
변화사항 : 바로 누웠다가 앉았다가 할 수 있음, 불변사항 : 여전히 개호인 한명이 필요함
When stating that the patient's status is unchanged, it is important to make sure that all of the evaluation skills and methods available have been used.
환자의 상태가 변화하지 않은 것을 서술할때에는, 평가기술들과 사용되어진 가능한 방법들의 모두를 정확히 하는것이 중요하다.
In the example above, perhaps the amount of assistance needed by the patient is unchanged, but the patient is performing the transfer more quickly (5 minutes to perform the transfer versus 10 minutes).
위의 예에서, 아마도 개호인은 변화없는 환자를 위해 필요했으나, 환자는 더 빨리 변화사항을 수행할 수 있다. (변화사항을 이행하기 위해선 5분 걸림 : 10분)

EXAMPLE (CORRECT)
Transfers : Supine ↔ sit unchanged ; still requires mod + assist. but performance of transfer requites 5 min. on this date (vs. 10min. initially required). Transfer is becoming more functional.
변화사항 : 바로 누웠다가 앉았다가 할 수 있음, 불변사항 : 여전히 개호인이 필요함. 그러나 변화사항을 수행함에 있어서 오늘 5분 걸림. (원래 10분이 걸림) 변화사항은 점점 더 기능적이 되어감.
Date used for comparison purposes can also be included.
비교의 목적으로 날짜를 쓰는 것 또한 포함된다.
In the example above, without the comparative data, the fact that the performance of the transfer required 5 minutes would seem insignificant to the reader.
위의 예에서, 비교할만한 날짜가 없으면, 변화사항을 수행하기 위해 5분이 걸린다는 사실은 차트를 읽는 사람에게 대수롭지 않은 것으로 보여질 수 있다.
The reader may not take the time to look at a previous written note in order to obtain the patient's former status, or the reader may not have the previous note available.
차트를 읽는 사람은 환자의 이전상태를 확인하기 위해 전에 쓴 노트를 보지 않을 것이고 혹은 차트를 읽는 사람이 사용가능한 전의 노트를 참고하지 않을 수도 있다.
Information addressed in interim notes should include areas addressed in the last set of short term goals written.
임시노트에서 지정된 정보는 단기목표의 마지막 세트에 쓰여진 지정된 부위를 포함해야 한다.
For example, if a goal is set for the patient to be able to roll supine →sidelying ⓡ(대문자) independently within 1 week, the patient's rolling status should be addressed under O in the next interim note.
예를 들어, 만일 목표가 혼자서 1주일 내에 환자가 반드시 누웠다가 옆으로 눕게되는 것이라면, 환자의 움직임의 상태는 다음 임시노트에서 0이하로 지정되어야 한다.
As mentioned previously, when writing notes, it is important ot know the requirements of both the facility and the third-party payers.
앞에서 언급했다시피, 차트를 쓸때는, 이것이 중요한지 아니면 설비와 제3의 치료자에게 알려질 필요가 있는지를 명시해야 한다.
In some areas of the country, certain third-party payers require listing both the treatment the patient received and the patient's reaction to the treatment.
다른 지역에서는, 어떤 제3의 치료자는 환자가 받은 치료와 치료에 대한 환자의 반응에 대한 리스트를 요구할 수도 있다.
This can be listed in the O part of the note under reaction to treatment.
이것은 치료에 대한 반응을 한 차트의 0부분 부터의 리스트가 될 수도 있다.

EXAMPLE (CORRECT)
Reaction to Rx : Pt. received 30 min. of gait training on this date emphasizing correction of gait deviation & correction of balance deficits.
처방에 대한 반응 : 이 날짜의 날에 한쪽으로 치우쳐 걷는것을 교정하고 균형의 결함을 교정하는 것을 중점적으로 걷는 연습30분을 함
Responded well to verbal cues but could not cont.to correct gait deviations s (위에줄) verbal cues
말로 신호를 주는 것에 반응을 잘 하지만 치우쳐 걷는 것을 교정할 수는 없었다.

Writing Discharge Notes
이행차트 쓰기
The completeness of the O section of a discharge note varies greatly among practice settings.
이행차트의 0 부분의 완벽함은 연습셋팅 사이에서 매우 다양하다.
In some facilities, the discharge note is similar to an interim note and is an update of the patient's status since the last interim note was written.
몇몇 시설들에서, 이행차트는 임시차트와 비슷하며, 마지막 임시 차트에 쓰여진 이후의 환자의 상태 변화를 적는 것이다.
In other facilities, the discharge note is a more complete summary of the patient's condition upon discharge from the facility and, in format and length, is more similar to the initial note.
몇몇 시설들에서, 이행차트는 다른 과에서 시행한 것에 대한 환자상태의 더 완벽한 요약을 의미하며, 형태나 길이면에서 볼때 임시차트와 매우 비슷하다.
Still other facilities use a format that summarizes the patient's condition upon beginning therapy, the general course of therapy, and the patient's status upon discharge from therapy.
아직도 다른 과에서는 치료시작과 치료의 일반적 과정, 그리고 치료를 했을 때 환자의 상태와 같은 환자의 컨디션을 요약하는 형태를 사용하고 있다.

Types of notes can also vary depending upon who will be reading the note.
차트의 타입은 또한 그 차트를누가 읽느냐에 따라 달라진다.
For example, a note that is forwarded to a nursing home or home health agency might be a complete summary of the patient's condition, whereas a note that will go the medical records storage when the patient is discontinued may simply update the patient's status since the last interim note was written.
예를 들어, 간호부나 가정주치의들이 읽을 차트는 환자의 컨디션을 완벽하게 요약해야 한다. 반면 환자가 퇴원하여 의료기록부로 가는 차트들은 마지막 임시차트이후의 환자의 상태만 적어서 내면 된다.
The home health or nursing home therapist may receive only the discharge summary from an acute or rehabilitation facility, so a more complete note is needed.
가정주치의나 가정치료간호사는 단지 단기 혹은 재활시설로부터 받은 치료요약만을 받을 수도 있는데 그것은 더 완벽한 차트가 필요하기 때문이다.
For the purposes of this workbook, the discharge note is to be considered a complete summary of the patient's status upon discharge and course of therapy, and you are to address all areas of objectives data measured and / or remeasured during treatment.
이 교재의 목적은, 이행차트는 치료의 이행과 과정을 통한 환자상태의 완벽한 요약을 해야 하고, 당신이 치료하는 동안 측정되고 재측정된 해당부위의 모든 것을 지정해야 한다는 것이다.

Summary
요약
The O section of the note is a very important section.
차트의 0부분은 매우 중요한 부분이다.
It should be included in every type of note, whether it is an intial, interim, or discharge note and whether a traditional SOAP format or a SOAP format using functional outcomes as its emphases is used.
이것은 차트가 초기이든 임시이든 이행차트이든간에, 또한 전통적인 SOAP형태이든 강조사항이 있는 기능적 산출을 사용한 SOAP형태이든간에 모든 종류의 차트를 포함한다.
The information should be organized under headings, should be written in a clear and concise manner, and should list the results of objective measurement procedures performed by the therapist.
정보는 제목하에 배치되어야 하고, 명료하고 간결한 형태로 쓰여져야 하며, 치료사에 의해 수행된 측정의 결과를 명시해야 한다.
The following worksheets give practice at the skills needed to write the O part of a note.
다음 문제지는 차트의 0부분을 쓸때 필요한 기술에 대한 연습이다.
Four worksheets are included because this portion of the note includes so many different types of information.
문제지는 4장인데 그 이유는 차트의 이 부분이 너무 많은 다른 정보의 타입을 포함하고 있기 때문이다.
After reviewing this chapter, working with the following worksheets.
이 장을 다시 읽은 후에, 다음의 문제지를 풀어보자.
and using the answer sheets to correct the worksheets, you should be able to write the objective portion of a note easily
그리고 문제지에서 정답을 골라 답안지에 쓰고, 당신은 쉽게 차트의 목적된 부분을 쓸수 있을 것이다.

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