Archives of health of whole family medical health

Respiration 3D Medical Animation

Archives of health of whole family medical health

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Meaning

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Characteristic

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Basic content

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Use and manage

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Put the issue that be in

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Some cadre, one‘s early years ever played a Red Army man, attended war of liberation, the War to Resist Us Aggression and Aid Korea. In the country Ministry of Public Health becomes sectional leader after.

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80 time, when undertaking to its the body is checked, x piece show its are right lobar shadowiness, the others body is asked for all be negative. Oneself do not have unwell symptom self-consciously also. Director doctor is discreet for the purpose of, combine other expert consultation, 10 people are divided distrustful attitude is supported outside one person, oneself think to do not have disease stoutly. Had planned to was checked all right again in June, the result is Alexandrine second. This, do 10 people suspect is there lung cancer? Oneself also remove suspicion, feel oneself the whole body is lack of power, aching, uncomfortable.

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Open pectoral operation, show without any focus of a disease.

One, the sense that establishs healthy record

1. provides the patient‘s overall foundation data, it is whole family doctor comprehensive understanding patient is individual reach domestic problem, make correct and clinical decision-making main base.

Fission is filled to show biology on 2. record form and content - psychology - social medical mode

Healthy record is consecutive and medical health of 3. whole family is comprehensive

The healthy archives of 4. whole system is a when doctor itself undertakes continueing to teach important resource

The form that archives of medical health of 5. whole family records and content were overcome before too simple, non-standard, medical health and legal effectiveness differ outpatient service case of illness wait for defect, the copy clerk of medical health law with become basic level whole family to serve a field important

6. is those who prevent medical to carry out provide a data

7. evaluates whole family doctor to serve one of tools of quality and level of medical health technology

Problem of sanitation of family of the healthy condition that 8. offers community resident, community and wholesome resource, use social natural resources to provide assistance to the dweller

2, the characteristic of archives of health of whole family medical health

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What whole family medical health reflects is it is with the person this, the government that has all-around, whole process for the center with health

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Healthy archives can reflect principle of whole family iatrical and service characteristic

In formallyUnified, compendious, practical

Have on contentIntegrality, logic, accuracy, earnest sex and standardization

3, the record pattern of healthy archives

Record pattern for what direct with the disease (Disease/doctor Oriented System, DOS)

Record pattern for what direct with the problem (Problem-oriented Medical Record, POMR)

Record pattern for what direct with the disease (Disease/doctor Oriented System, DOS)

The medical health with the most commonly used tradition records pattern

Content of case of illness is multifarious, not easy and rapid control patient the progress circumstance of its health problemThe data is dispersive, not easy concentration considers and judge the patient‘s potential healthy problemIts format makes its content and thinking kind understand each other hard between different doctor, cause communication difficulty

Record pattern for what direct with the problem (Problem-oriented Medical Record, POMR

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Put forward by Weed 1969

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1970, bjorn added provisionality problem catalog,

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Grace added domestic problem catalog again 1997. Be used above all in the United States,

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Current, in the anamnesis record of the basic level medical health of world each district and large hospital use POMR means extensively to have a record.

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Record pattern for what direct with the problem (Problem-oriented Medical Record, POMR)

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Include commonly:

Patient foundation data

Ask the title records: Cent basically is mixed temporary two kinds

Problem description (SOAP form)

Flow of course of diseases

Ask the title is recorded

1. basically asks the title records:

Show the past was affected commonly, the unusual situation that be being affected now or still can affect individual health in the future (disease and life incident) .

The problem is made clear quite commonly.

2. provisionality / be restricted oneself sexual problem catalog:

Record acute or short-term problem commonly.

Problem description and course of diseases are recorded

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The core of POMR, cent SOAP4 part

S: Subjective data (Subjective Data)

O: Objective data (Objective Data)

A: Evaluate (Assessment)

P: Plan (Plan)

4, the content of archives of health of whole family medical health

Individual health archives

Domestic health archives

Community health archives

(one) individual health archives

1. individual health asks the preface is recorded

(1)Basic material of the patient:

Clinical and demography, healthy behavior, basic material (go to already history, go to already data of domestic history, biology, precaution data, drug allergy history)

(2)Ask the title is recorded:

(3)SOAPFormal problem description and problem progress are recorded

(4)Special difficulty has flow/Along with seek record sheet

(5)Assay reachs auxiliary examination

(6)Turn consultation record

The basic material of individual health archives

Form 1-10

2.Precaution is oriented record

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Precaution of whole family medical health serves a method to include to have:

Periodic checkup

Vaccinate... ... ... ... . . . (normative already)

Children grows to be evaluated with development... ... (normative already)

Patient education

Critical factor sieve is checked reach an opinion

(2) domestic health archives

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Include:

The family is basic data: Full name, sexual distinction, age, profession

The family evaluates a data: Genealogical graph, family shows loving care for an index to wait

The family is main problem: Record the major problem that produces in the family

Problem description

Archives of health of domestic member individual

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The family that at present whole family medical health uses extensively evaluates a method to have: The family shows loving care for an index (APGAR questionnaire) , group of genealogical graph, family.

(one) the family is basic data

Include the basic material of every domestic member, if full name, sexual distinction, age, part, profession, education, marriage reachs main and healthy problem to wait, and domestic type, internal composition, living environment, healthy belief.

(2) the family evaluates a data

Genealogical graph, family shows loving care for an index to wait

1.Genealogical graph

It is important that genealogical graph can use heredity of descriptive family structure, family to ask member of problem, family correlation, family the circumstance such as incident. It can make whole family doctor masters a family quickly to concern healthy fundamental case and important information. Domestic attempt compares stability relatively, change won‘t be too big, the basic material that can regard a family as archives is put in anamnesis.

Graph 12345

The note of genealogical graph scale

Genealogical graph is comprised by 3 generation commonly. Elder is in on, descendants is falling; In compeer, better is in left, young person be in right; The family of connubial both sides should be included inside. On the side of the individual‘s symbol, can add by need record the life event such as the age, anamnesis, marriage, death. Can be in commonly 5 ～ are finished inside 15 minutes. The symbol that its use has definite pattern.

Particular operation

Family doctor can leave a little while, make some family member independent finish (need 10-15 only commonly minute) , subsequently, the doctor puts questions to its or let its explain the implication of the graph, understand its domestic situation thereby. The doctor still can compare the family of member of two different families to encircle, and with they or family a trade off study, the analysis lacks the expectation that communication respect or those differ here between them, made modification part, improve domestic function.

Because of change and be being amended continuously

What what domestic group mirrors is some family member the subjective view that concerns to the family currently, be can constant change, need to be amended continuously consequently. It is the simple method of structure of family of a kind of understanding and function, can regard an evaluation as the jumping-off place of domestic function obstacle

(4) domestic care index is evaluated

Assessment purpose analyses domestic member to be spent to the subjective satisfaction of domestic function to pass namely will evaluate a family to be opposite healthy influence level.

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Basically be to the family the function undertakes assessment,

Separate 5 sides:

Fitness (Adaptation)

Collaboration is spent (Partnership)

Into length (Growth)

Affection is spent (Affection)

Spend intimately (Resolve)

•-- -- SmilksteinAPGAR questionnaire, 1978

Domestic care spends an index (APGAR)

Domestic care spends an index to evaluate a quantity to express is Smilkstein design detect the questionnaire of domestic function, it is one kind is compared handy, can mirror domestic member to be opposite the subjective and satisfactory rate of domestic function. Because its problem is less, grading is easy, OK and rough, apace evaluates domestic function, it is whole family doctor consequently most commonly used family evaluates a method. It divides composition by two.

The family is main problem

Watch

(3) community health archives

Include

Sanitation of community of resource of service of sanitation of basic material community serves community condition of health of state community dweller

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Community is basic data:

Community environment -- pathogeny explore examine

Community economy and constituent state, healthy education

Community arouses latent capacity -- urgent relieve a sick or injured person

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Community sanitation serves resource:

Wholesome service orgnaization and manpower resource -- turn in time examine

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Community sanitation serves a state

Sort of disease of reason of outpatient service quantity, patient seeing a doctor, outpatient service and form, turn consultation disease is planted, circumstance of domestic sickbed number, be in hospital

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Condition of community dweller health

Demography data: Amount, form,

Problem of community dweller health distributings reach serious level

Disease chart, mortality

Critical factor evaluates dweller fitness: If food is used to. Lack takes exercise etc

4, of healthy archives build and manage

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Handwriting clear, problem description is accurate and complete, true, accord with logic;

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Keep dynamic successional

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Encode: A. Classify ICPC-2/ICD-10/ICHPPC-2 by international

B. Voluntary code system

International of basic level medical health classifies ICPC

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It is before 1970, collect the data such as the incidence of a disease in basic level medical health, use international disease to classify (Internationalclassification Of Disease, ICD)

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As WONCA the organization held water 1972, considered technically to agree with international of basic level iatrical classifies a system, published ICPC 1987 the first edition. Published the second edition 1997, exam of world each country tried to use ICPC the second edition 1998.

Domestic health archives proposes archives way

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Establish record of health of front courtyard of one a member of the same clan to each;

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Combine what whole family medical health serves to begin bring into relevant domestic data stage by stage individual health archives, and establish domestic health record alone not simply. For instance: Basic material, life cycle assesses member of genealogical graph, family etc.

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The management of healthy archives

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Benefit undertakes administrative with the computer

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Record pattern SOAP (WONCA of society of world family doctor is recommended)

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The unified development of software is used

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Show the issue that level health archives exists

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The ignored on the thought, oversight its importance

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Practice and theory are not accorded with

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Computer government rate is not high

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Level of technology of software of computer form a complete set is low, use inconvenience

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Establish archives rate: 1. Low
2. is not low, the key is not outstanding

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The quality that build archives is not high: Copy house appoint data of meeting registered permanent residence; The project is lacked much; Level of archives form design is low, make durative service possible reduce etc

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Dead grade issue: Build amount of healthy archives brief of a case to assure, but use not much

Whole family advocate treat doctor exam example 2001

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One, ABC

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The purpose of genealogical graph

Make summary undertake to domestic function affective of human to the family relation is described descriptive descriptive domesticity cycle to describe domestic natural resources to domestic background and potential healthy problem

Standard answer: A

Much selection of subject

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The purpose that the family evaluates

The major event patient that the level understanding that the relation understanding family that undertakes community diagnoses understanding family member grows produces in domesticity can get from inside the family those are helped

Standard answer: BCDE