表格式住院病例中英版POMR.pdfVIP

POMR(Problem-OrientedMedicalRecords)

表格式住院病历

Biographicaldata:

一般项目：

NameAgeSexMaritalstatusNativityRace

姓名年龄性别婚否籍贯民族

OccupationDateofadmissionInformantHistory

职业入院日期病史叙述者病史

Chiefcomplaint

主诉

Historyofpresentillness

现病史

Pasthistory

既往史：

Previoushealthstatus:wellordinarybadInfectiousdiseases

平素健康状况：良好一般较差传染病史

ImmunizationsAllergies:NYclinicalmanifestation

预防接种史过敏史无有临床表现

allergen:Trauma:Surgery:

过敏原外伤史手术史

Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpostive,

youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnose

andtherapy)

系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及

扼要诊疗经过)

Respiratorysystem:

呼吸系统

Sorethroatchroniccoughsputumhemoptysiswheezing

咽痛慢性咳嗽咳痰咯血哮喘

dyspneachestpain

呼吸困难胸痛

cadiovascularsystem:

循环系统

Palpitationdyspneaonexertionhemoptysissyncope

心悸活动后气促咯血晕厥

edemaoflowerlimbsprecordialpainhypertention

下肢水肿心前区疼痛高血压

Digestivesystem:

消化系统

Anorexiasourregurgitationbelchingnauseavomitting

食欲减退反酸嗳气恶心呕吐

abdominaldistentionabdominalpainconstipationdiarrhea

腹胀腹痛便秘腹泻

hematemesismelenahematocheziajaundice

呕血黑便便血黄疸

Urinarysystem:

泌尿系统

Lumbagofrequentmictur