Pomr (Problem-Oriented Medical Record) was first proposed by Weed et al. in 1968 in the United States, requiring doctors to adopt individual health problem-oriented records in medical services. The advantages are: individual health problems are concise, focused and clear, which is convenient for computer data processing and management. At present, it has become the basic method to establish residents' health records in many countries and regions in the world.
POMR recording method generally includes the basic information of individuals and their families, the catalogue and description of health problems, the progress of problems, flow charts and so on. Community health service personnel must fill in carefully according to the format requirements.
(1) Personal health records: mainly including: 1, personal basic information of patients. ① Demographic data: such as age, gender, education level, occupation, marriage, race, socio-economic status, ID number, etc. ② Health behavior data: such as smoking and drinking, including habits, exercise and seeking medical treatment. ③ Clinical data: past history, family history, basic biological data, preventive medical data (records of immunization and regular health examination), psychological evaluation, behavior and other data. 2. List of health problems. It is the main content of health record, and the content of the record refers to the problems that have affected personal health in the past, are affecting personal health now or will affect personal health in the future. It can be a definite or vague diagnosis, unexplained symptoms, signs or laboratory results, or it can also be a social, economic, psychological and behavioral problem (such as unemployment, widowhood, deviant behavior, etc.). ). Health problems are divided into main problems and temporary problems. If time does not allow, only the main health problems can be listed, and temporary problems can be recorded in the daily medical record of SOAP, and doctors are required to summarize them regularly. 3, the disease flow chart. It is a summary of the progress of a major problem in a certain period, which generally reflects the dynamic change process of some important indicators related to the problem, such as chief complaint, symptoms, physiological and biochemical indicators and some special examination results, medication methods, side effects of drugs, diet therapy, behavior and lifestyle changes, psychological test results, etc. The disease flow chart is mainly used to record the observation and treatment of chronic diseases and some special diseases, and not all health problems are needed. The items recorded in the flow chart of different diseases can also be different. 4, problem description and progress record. It is the core part of POMR and a detailed record of each patient's visit. Firstly, the main health problems of individuals are listed as the main problem list, and then each problem in the problem list table is described in the form of SOAP. The patient's subjective data are chief complaint, symptoms, medical history, family history, social life history, etc. Provided by the patient. Try to record it according to the patient's statement. O: objective data, which records the data observed by medical staff in the process of diagnosis and treatment, including physical signs, laboratory examination, X-ray diagnosis, psychological and behavioral test results of patients, etc. A: The assessment of health problems is a key part of the problem description. A complete evaluation should include diagnosis, differential diagnosis, relationship with other problems, severity of problems and prognosis. This kind of assessment is different from the diagnosis results centered on diseases, and its content can be diseases, psychological problems or social problems, or symptoms or complaints of unknown reasons. If the problem is a combination of multiple symptoms, discomfort or related examination data, the final biological diagnosis may not be made because of the disappearance of symptoms or discomfort. P: A problem-solving plan is a plan for diagnosis, treatment, prevention, health care, rehabilitation and health education for each problem. 5. Regular physical examination is a health examination project designed for individuals with different ages, genders and health risk factors to find and diagnose early. The regular health examination plan is mainly made through personal opportunity visit or doctor's home visit. 6, turn consultation and hospitalization records. One of the important tasks of family medical care is to use all kinds of necessary medical and social resources to serve patients. Referral is one of the ways for family doctors to communicate with their peers and use other medical resources. The destination of patient referral can be other primary doctors, specialists, nurses, therapists, social workers, etc. It is decided by the family doctor according to the specific situation of the patient. The general practitioner's referral record is two-way. 7. Prevention records. Preventive medical services in general practice include regular health examination, vaccination, health education and risk factor screening. The purpose is to find patients and risk factors early and intervene. Among them, regular health examination is an important measure to embody preventive service in foreign primary health care. In China, at present, only the planned immunization program for children and some maternal and child health care programs are standardized, and other services have not yet reached unity. General practitioners can try to provide preventive medical services suitable for the needs of residents in this community according to the specific conditions of patients in this community. 8, chronic disease prevention records. Fill in the follow-up records of chronic diseases such as hypertension and diabetes with specially designed forms, and record the symptoms, signs, laboratory tests, complications and medication of patients in chronological order, the target departments and treatments referred, the progress of health education guidance and implementation, and the effect evaluation. 9, laboratory and auxiliary inspection records. The content depends on the patient's health. It can also be designed as a table to fill in the inspection results at any time to avoid the file being too thick.
(2) Contents of family health records: including basic family data, genealogy, family evaluation data, catalogue of major family problems, problem descriptions and personal health records of family members (the form and contents are the same as those of personal health records).
(3) Contents of community health records: mainly including 1, basic community information. Including the natural environmental conditions of the community, such as the geographical location, scope, natural climate and environmental conditions, sanitary facilities and sanitary conditions of the community; Demographic characteristics of the community, such as the total population, age and gender composition (population pyramid), birth rate, mortality rate, natural population growth rate, ethnic characteristics, fertility concept, etc. The humanistic and social environment of the community, such as the education level, religious traditions and customs, consumption level and consciousness of community residents, the development and role of social groups, family structure, marital status, family functions, public order, etc. ; The economic and organizational situation of the community, etc. 2. Community health resources. Including community health service institutions and health human resources. 3. Present situation of community health service. Including outpatient statistics, outpatient volume, outpatient content, classification of patients' reasons for seeing a doctor, classification and composition of common health problems, utilization of health services, patient transfer rate and suitability analysis, etc. 4. Health status of the community. Including the distribution and severity of community health problems, such as the incidence, prevalence and disease composition, mortality and disability rate of community population; Assess the health risk factors of community residents, such as eating habits, lack of exercise, tense working environment, life stress events, interpersonal tension, medical treatment behavior, obstacles to access to health services, etc. Community disease spectrum, age, sex and occupation distribution, cause of death spectrum, etc.