以病人问题为导向的医疗记录Problemlist(问题列举.PDFVIP

療 錄 Problem list ( 列) SOAP 療 錄 (POMR) 1 年 • 療 錄POMR 理療 料 療 錄 療 錄 POMR 2 POMR 歷 料 ‧ 數 行 ‧理 ‧ Analysis of symptoms 1.LQQOPERA 2.TINA 3.Who, When, Where, what, How, Why 3 LQQOPERA Analysis of symptoms Location () Quality () Quantity/time course (歷 ) Onset mode (狀 ) Precipitation factors () Exaggerating factors () Relieving factors () Accompanying symptoms ( 狀) History taking (knee pain): CHLORIDE FPP • Character: What does the pain feel like? Do you have any stiffness? • Location: Where is the pain (what part of knee?) Pain in any other joints? • Onset: How did this start (sudden, acute, insidious ?) • Radiation: Does the pain move anywhere? • Intensity: How severe is the pain ? How dose it affect your daily activity ? • Duration: How long doses the pain last (intermittent, chronic) • Events associated: redness, swelling, deformity, muscle atrophy, Raynaud’s phenomenon, conjunctivitis, oral ulcer • Frequency: How often does it happen ? • Palliative factors: What (activity vs rest) makes it better? • Provocative factors: What (stair climbing) makes it worse? 4 The structure of POMR POMR : 列(Problem list) • POMR 錄 5 列 ‧ 糖尿 狀尿