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以问题为导向的病历记录(问题定向病案Problem-Oriented Medical Record,简称POMR),又称疾病导向病历(Diagnosis-Oriented Medical Record)是病人海一次诊疗情况的详细记录,强调问题的突出地位。方法采用POMR书写病程记录要求医师一律按SOAP(Subjective Objective Assessment Plan)的形式进行记录。即(1)S(Subjective)主观资料,包括
The Problem-Oriented Medical Record (POMR), also known as the Disease-Oriented Medical Record, is a detailed record of the patient’s first diagnosis and treatment, highlighting the prominence of the problem. Methods The POMR writing history records required that physicians record in the form of SOAP (Subjective Objective Assessment Plan). That is, subjective information of (1)S (Subjective) includes