以问题为导向的病历(POMR)通过引入一种系统的方法来关注患者的问题,而不仅仅是罗列症状,从而彻底改变了医疗记录保存方式。劳伦斯·韦德(Lawrence Weed)博士在20世纪60年代便引入了这种方法,这标志着医疗记录的重大进步。以问题为导向的病历框架由四个关键部分组成:数据库、问题列表、护理计划和进展记录。
以问题为导向的病历的优点:
以问题为导向的病历的缺点:
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