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1、POMR(Problem-OrientedMedicalRecords)表格式住院病歷Biographicaldata:一般項(xiàng)目：NameAgeSexMaritalstatusNativityRace姓名年齡性別婚否籍貫民族OccupationDateofadmissionInformantHistory職業(yè)入院日期病史敘述者病史Chiefcomplaint主訴Historyofpresentillness現(xiàn)病史Pasthistory既往史：Previoushealthstatus:wellordinary
2、badInfectiousdiseases平素健康狀況：良好一般較差傳染病史ImmunizationsAllergies:NYclinicalmanifestation預(yù)防接種史過(guò)敏史無(wú)有臨床表現(xiàn)allergen:Trauma:Surgery:過(guò)敏原外傷史手術(shù)史Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpostive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandt
3、herapy)系統(tǒng)回顧：(有打√無(wú)打×陽(yáng)性病史應(yīng)在下面空間內(nèi)填寫(xiě)發(fā)病時(shí)間及扼要診療經(jīng)過(guò))Respiratorysystem:呼吸系統(tǒng)Sorethroatchroniccoughsputumhemoptysiswheezing咽痛慢性咳嗽咳痰咯血哮喘dyspneachestpain呼吸困難胸痛cadiovascularsystem:循環(huán)系統(tǒng)Palpitationdyspneaonexertionhemoptysissyncope心悸活動(dòng)后氣促咯血暈厥edemaoflowerlimbsprecordialpai
4、nhypertention下肢水腫心前區(qū)疼痛高血壓Digestivesystem:消化系統(tǒng)Anorexiasourregurgitationbelchingnauseavomitting食欲減退反酸噯氣惡心嘔吐abdominaldistentionabdominalpainconstipationdiarrhea腹脹腹痛便秘腹瀉hematemesismelenahematocheziajaundice嘔血黑便便血黃疸Urinarysystem:泌尿系統(tǒng)Lumbagofrequentmicturitionur
5、gentmicturitionurodynia腰痛尿頻尿急尿痛dysuriahematurianocturiapolyuriaoliguriafacialedema排尿困難血尿夜尿多尿少尿面部水腫Hematopoieticsystem造血系統(tǒng)Fatiguedizzinessblurredvisiongingivalbleedig乏力頭昏牙齦出血subcutaneoushemorrhageostealgiaepistaxis皮下出血骨痛鼻衄Metabolicandendocrinesystem:代謝及內(nèi)分泌系
6、統(tǒng)Excessiveappetiteanorexiasweatscoldintolerance食欲亢進(jìn)食欲減退多汗畏寒polydipsiatremorhandschangeofcharacterobviousobesity多飲雙手震顫性格改變顯著肥胖emaciationhirsutismhairlosingpigmentation消瘦多毛毛發(fā)脫落色素沉著changofsexualfunctionamenorrhea性功能改變閉經(jīng)Musculoskeletalsystem肌肉骨骼系統(tǒng)Floatingarthr
7、algiaarthraligaswellingofjoints游走性關(guān)節(jié)痛關(guān)節(jié)痛關(guān)節(jié)紅腫deformiteiesofjiontsmyalgiaatrophyofmuscle關(guān)節(jié)變形肌肉痛肌肉萎縮Nervoussystem神經(jīng)系統(tǒng)Dizzinessheadachevertigosyncopedegenerationofmemory頭昏頭痛眩暈暈厥記憶力減退visualdisturbanceinsomniadisturbanceofconsciousness視力障礙失眠意識(shí)障礙tremorspasmparaly
8、sisparesthesia顫動(dòng)抽搐癱瘓感覺(jué)異常Personalhistory:個(gè)人史BirthplaceOccupationsexualhistorysmokingNY出生地職業(yè)冶游史吸煙無(wú)有aboutyearsaveragepiecesperdayceasedforyears約年平均支/日戒煙年alcoholintakeNoccasionalfrequentaboutyears嗜酒無(wú)偶有經(jīng)常約為年averag
