电子医疗系统中的问题导向病历编写指南
Problem Oriented Medical Record (POMR) has been a standard of physicians’ record since it was introduced in 1968 by Dr. Lawrence Weed. However, many physicians are unaware of its principles and do not apply it in a correct way in clinical practice. This book will describe how to systematically write medical records for the diagnostic and therapeutic approaches. This book will cover principles and practice of POMR for care of inpatients and outpatients. The importance of medical records cannot be overemphasized, but many trainees are not educated for the right way of POMR. Thus, this book will provided the right concept of POMR and correct way of medical writing, compatible with the principles of POMR.
问题导向的医疗记录(POMR)自1968年由劳拉德·韦德医生引入以来,一直是医生产记录的标准。然而,许多医生并不了解其原则,并且没有正确的方式将其应用于临床实践。这本书将描述如何系统地为诊断和治疗方法编写病历。此书将涵盖POMR的原理与实践,用于住院病人和门诊病人的护理。医疗记录的重要性无法被过分强调,但许多培训学员并没有接受正确的POMR教育方式。因此,本书将提供正确的POMR概念以及与POMR原则相兼容的正确病历编写方法。
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