1.POMR (Problem-Oriented Medical Records)表格式住院病历
奋斗新时代2.Biographical data: 一般项目：
3.Name Age Sex Marital status Nativity Race
姓名年龄性别婚否籍贯民族
4.Occupation Date of admission Informant History
职业入院日期病史叙述者病史
5.Chief complaint 主诉
辣鸡做法6.History of prent illness 现病史
Past history 既往史：
7.Previous health status: well ordinary bad Infectious dias
平素健康状况：良好一般较差传染病史
8.Immunizations Allergies: N Y clinical manifestation
预防接种史过敏史无有临床表现
9.allergen: Trauma: Surgery:
过敏原外伤史手术史
10.Review of systems: (Tick if positive, cross out if negative. If postive, you should write down your dia history and brief cour of diagno 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) 11.Respiratory system: 呼吸系统
12.Sore throat chronic cough sputum hemoptysis wheezing
咽痛慢性咳嗽咳痰咯血哮喘
13.dyspnea chest pain
呼吸困难胸痛
14.cadiovascular system:
循环系统
15.Palpitation dyspnea on exertion hemoptysis syncope
心悸活动后气促咯血晕厥
16.edema of lower limbs precordial pain hypertention
下肢水肿心前区疼痛高血压
民族自信
Digestive system:
消化系统
Anorexia sour regurgitation belching naua vomitting
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0
Metabolic and endocrine system:
代谢及内分泌系统
Excessive appetite anorexia sweats cold intolerance
食欲亢进食欲减退多汗畏寒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
消瘦多毛毛发脱落色素沉着
chang of xual 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:
个人史
Birthplace Occupation xual history smoking N Y
出生地职业冶游史吸烟无有
about years average pieces per day cead for years
约年平均支/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
平均ml/日其他
Marital history:
婚姻史：
Marrying age companion’s state of health
结婚年龄配偶健康状况
Menorrhea and Childbearing:
月经及生育史
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 menopau)
绝经年龄
Amount of flow: little normal large menstrual pain: N Y
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 dias and
communicable dias and communicable dieas related to the paitent
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 cau of deaths mother:
父：健在患病已故死因母still alive illness died cau 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
pul脉搏/min次/分
respiration呼吸/min次/分
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痛苦传媒是做什么工作
anxious忧虑
dreadful恐惧
indifferent淡漠
Position: active mi-recumbent others
体位：自主半卧位其他
Gait: normal abnormal
步态正常不正常
Conciousness: aware somnolence confusion stupor coma
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）
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: 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: 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）
问君何能尔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）
No: shape : normal: abnormal ( ) other abnormalities:N Y
鼻外形正常异常（）其他异常无有
薄荷驱蚊吗Nosalala flap obsruction excretions nasal sinus tenderness:
鼻翼扇动鼻塞分泌物鼻旁窦压痛
N Y (position )
大便酸臭味是什么原因无有（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9
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:regular edentulous carious teeth
铅线牙列齐缺牙—|— 龋齿—|—
Tonsils: pharynx: voice: normal hoar
扁桃体咽声音正常嘶哑
Neck:resistence:N Y carotid artery pulsation: normal incread
颈部抵抗感无有颈动脉搏动正常增强
decread (left right) jugular vein:normal distention
减弱（左右）颈静脉正常充盈high distention trachea:middle deviation to (left right)
怒张气管正中偏移（向左向右）9
Hepatojugular reflux-) (+) thyroid: normal swelling degree
肝颈静脉回流征：（-）（+）甲状腺正常肿大度
Symmetry 对称
Dominance in one side: spreading nodular:soft hard others :N Y
侧为主弥漫性结节性质软质硬其他无有
(tenderness tremor bruits)（压痛震颤血管杂音）
Chest topography:normal barrel chest pigeon chest funnel chest
胸部胸廓正常桶状胸鸡胸漏斗胸
flat chest bulging or retraction (left right )扁平胸膨隆或凹陷（左右）
bulging in the precordial region tenderness of sternum
心前区膨隆胸骨压痛
Breast: normal symmetrical abnormal : left right(gynecomastia
乳房正常对称异常左右（男乳女化mass tenderness excretions of nipples)
包块压痛乳头分泌物）
Recorder
病史记录者
Examiner
并使审阅者
南京出租车Date of record
记录日期3
Lung
肺
Inspection : movement of respiration : normal abnormal : left
视诊呼吸运动正常异常左
