-
POMR (Problem-Oriented Medical
Records)
表格式住院病历
Biographical data:
一般项目：
Name
Age
Sex
Marital
status
Nativity
Race
姓名年龄性别婚否
xx
民族
Occupation
Date of admission
Informant
职业入院日期病史叙述者病史
主诉
History
of
present
illness
现病史
Past
history
既往
xx
：
Previous
health
status:
well ordinary bad
Infectious diseases
平素健康状况：
良好一般较差传染病
xx
Immunizations
Allergies:
N Y
clinical manifestation
预防接种
xxxxxx
无有临床表现
allergen:
Trauma:
1
/
25
History
Surgery:
过敏原外伤
xx
手术
xx
Review of systems:
(Tick if
positive, cross out if negative. If postive, you
should write down your
disease history
and brief course of diagnose and therapy)
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
)Re
spiratory system:
呼吸系统
Sore throat chronic cough sputum
hemoptysis wheezing
咽痛慢性咳嗽咳痰咯血哮喘
dyspnea chest pain
呼吸困难胸痛
cadiovascular system:
循环系统
Palpitation
dyspnea on exertion hemoptysis syncope
心悸活动后气促咯血晕厥
edema
of lower limbs precordial pain hypertention
下肢水肿心前区疼痛高血压
Digestive system:
消化系统
Anorexia
sour regurgitation belching nausea vomitting
2
/
25
食欲减退反酸嗳气恶心呕吐
abdominal distention abdominal pain
constipation diarrhea
腹胀腹痛便秘腹泻
hematemesis melena hematochezia
jaundice
呕血黑便便血黄疸
Urinary
system:
泌尿系统
Lumbago frequent micturition urgent
micturition urodynia
腰痛尿频尿急尿痛
dysuria
hematuria nocturia polyuria oliguria facial edema
排尿困难血尿夜尿多尿少尿面部水肿
Hematopoietic system
造血系统
Fatigue
dizziness blurred vision gingival bleedig
乏力头昏牙龈出血
subcutaneous hemorrhage ostealgia
epistaxis
皮下出血骨痛鼻衄
Metabolic and endocrine system:
代谢及内分泌系统
Excessive appetite anorexia sweats cold
intolerance
食欲亢进食欲减退
xx
畏寒
3
/
25
polydipsia tremor hands change of
character obvious obesity
多饮双手震颤性格改变显著肥胖
emaciation hirsutism hair losing
pigmentation
消瘦多毛
xx
脱落色素沉着
chang
of sexual function amenorrhea
性功能改变闭经
Musculoskeletal system
肌肉骨骼系统
Floating
arthralgia arthraliga swelling of joints
游走性关节痛关节红肿
deformiteies of jionts myalgia atrophy
of muscle
关节变形肌肉痛肌肉萎缩
Nervous system
神经系统
Dizziness
headache vertigo syncope degeneration of memory
头昏头痛眩晕晕厥记忆力减退
visual disturbance insomnia disturbance
of consciousness
视力障碍失眠意识障碍
tremor
spasm paralysis paresthesia
颤动抽搐瘫痪感觉异常
Personal history:
4
/
25
个人
xx
Birthplace
Occupation sexual history smoking N Y
出生地职业冶游
xx
吸烟无有
about years average pieces per
day ceased for years
约年平均支<
/p>
/
日戒烟年
alcohol intake N occasional frequent
about years
嗜酒无偶有经常约为年
average ml per day others
<
/p>
平均
ml/
日其他
Marital history:
婚姻
xx
：
结婚年龄配偶健康状况
Menorrhea and Childbearing:
月经及生育
xx
Menarche
age cycle lasting for days date of last period
初潮每次持续时间末次月经时间
(age of menopause)
绝经年龄
Amount of
flow:
little normal large
menstrual pain:
N Y
5
/
25
经量少正常多痛经无有
cycle:
regular
irregular pregnancy times natural labor
经期规则不规则妊娠次顺产
times abortions times premature
delivery times
胎流产胎早产胎
stillbirths times difficult labor and
its condition
死产胎难产及病情
Familly
history (pay attention to the congenital diseases
and
家族史（注意与患者现病有关的遗传病和传染性疾病）
Father:
still
alive illness died cause of deaths mother:
父：
健在患病已故死因母
still alive illness
died cause of death siblings:
others:
健在患病已故死因兄弟姐妹子女其他
Physical
examination
体格检查
Vital signs
生命体征
:
Temperature
体温
pulse
脉搏
/min
次
/
分
respiration
呼吸
/min
次
/
分
6
/
25
B.P
血压
mmHg
General
Appearance
一般状况
:
Development
发育
:
ortho-sthenic
type
正常
asthenic
type
不良
sthenic
type
超常
nutrition
营养
:
well
良好
fairly
中等
poor
不良
cachexia
恶病质
Facial
features
面容
:
normal
无病容
acute
急性
chronic
慢性病容
others
其他
Expression
表情
:
natural
自知
painful
痛苦
anxious
忧虑
dreadful
恐惧
7
/
25
indifferent
淡漠
Position:
active
semi-recumbent others
体位：
自主半卧位其他
Gait:
normal abnormal
步态正常不正常
Conciousness:
神志清楚嗜睡模糊昏睡昏迷
delirium coppperatio; well badly
谵妄配合检查合作不合作
Mucocutaneous color:
normal red pale cyaosis stainted
皮肤粘膜色泽无病容潮红苍白紫绀
yellow pigmentation lesions:
N Y (type and distribution)
黄染色素沉着皮疹无有（类型及分布）
Subcutaneous hemorrhange:
N Y(type and distribution)
皮下出血无有（类型及分布）
8
/
25
Hair:
normal
reduced edema:
N Y(position
and degree)
头发分布正常减退水肿无有（部位及程度）
Hepatic palm:
N
Y spider angionma:
N
Y
（
position numbers
）
others:
肝掌无有蜘蛛痣无
有
(
部位数目
)
其他
Lymphnodes:
淋巴结
Superficial
lymph nodes:
non-swelling
swelling(position and characteristics)
全身淋巴结肿大无肿大（部位及特征）
Head :
cranium :
size :
normal large small deformity:
头部头颅大小正常大小畸形
N
Y(coxycephaly squared skull deforming skull)
无有（尖颅方颅变形颅）
Others:
9
/
25
tenderness mass sunk
(position)
其他异常：
压痛包块凹陷（部位）
Eyes
eyelid:
normal edema ptosis
trichiasis conjunctive :
眼睑正常水肿下垂倒睫结膜
normal hyperemia edema hemrrhage
正常充血水肿出血
eye ball:
normal
proptosis depression tremor
眼球正常突出凹陷震颤
motion
dysfunction(left right)
运动障碍
Sclera :
normal yellow
cornea :
normal abnormal (
left right )
巩膜无黄染有黄染角膜正常异常（左右）
Pupils:
equal
roundness same size unequal left cm
瞳孔等圆等大不等左
cm
reaction to light:
10
/
25
normal delay (left right)
disappear (left right)
对光反射正常迟钝（左右）消失
（左右）
Others:
其他
Ears:
auricle :
normal
deformity fistula others (left right )
耳耳廓正常畸形瘘管其他（左右）
excretions of external auditory canal:
N Y (left right feature)
外耳道分泌物无有（左右性质）
Tenderness of mastoid :
N Y audation dysfunction:
N Y (left right)
乳突压痛无有听力粗试障碍无有（左右）
Nose:
shape :
normal:
abnormal ( ) other abnormalities:
N Y
鼻外形正常异常（）其他异常无有
Nosala flap obsruction excretions nasal
sinus tenderness:
11
/
25
鼻翼扇动鼻塞分泌物鼻旁窦压痛
N
Y (position )
无有（部位）
Mouth lips :
red syanosis
pale herpes fissure mucosa :
normal
口唇红润发绀苍白疱疹皲裂粘膜正常
abnormal ( pale petechia)
异常（苍白出血点）
Opening
of parotid gland duct:
normal abnormal (swelling
腮腺导管开口正常异常（肿胀
suppurative excretions)
脓性分泌物）
Tongue:
normal abnormal (coverings tremor
leaning to left or right)
舌正常异常（舌苔伸舌震颤向左、向右偏斜）
Gums:
normal
swelling pus overflow hemorrhage pigments
牙龈正常肿胀溢脓出血色素沉着
lead line tooth:
12
/
25