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New POMR 及新增列功能說明

New POMR 及新增列功能說明. 2013 年 03 月 28 日 POMR 系統及新上線醫囑 說明. Progress note 中 POMR 書寫 原本 problem list 下 SOAP 改成相同 S.O. 不同 A/P A/P 内帶 problem ＃ 1 problem ＃ 2 只帶 problem, 不帶 goal ,inactive 會帶入. 一 . New POMR 畫面. S O A/P 範本. S: O: A/P

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New POMR 及新增列功能說明

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  1. New POMR及新增列功能說明 • 2013年 03月 28日 • POMR系統及新上線醫囑說明

  2. Progress note 中POMR 書寫 • 原本 problem list下 SOAP • 改成相同 S.O.不同 A/P • A/P 内帶problem＃1 problem ＃2 • 只帶 problem,不帶goal ,inactive會帶入

  3. 一. New POMR畫面

  4. S O A/P 範本 • S: • O: • A/P • Problem #1: Acute perforated appendicitis s/p appendectomy POD 3 with wound infection • A: Moderately febrile; Leukocytosis with left shift; No sign of peritoneal irritation. • P: • Diagnostic: Open up wound for drainage & follow pus culture results. • Therapeutic: Wound normal saline wet dressing every 4 hours. • Educational: Already informed patient of the need for opening the wound for drainage and explained to him the present treatment strategy. • Problem #2: Upper respiratory tract infection • A: No sign of tonsillitis. Influenza infection cannot be ruled out. No similar symptoms in other members of his family or among his colleagues. • P: • Diagnostic: Consider influenza screening. Follow results if patient agrees to undergo the test. • Therapeutic: Symptomatic treatment with acetaminophen 500 mg qid p.o. Brown mixture 15 ml qid p.o. Start Tamiflu 75 mg Bid p.o. x 5 days for proven influenza. • Educational: Inform patient of the limited sensitivity of influenza screening test (~70%) and the need for extra expenditure for the test. Explain to patient about the present treatment strategy.

  5. POMR 畫面新增異動畫面 (objective) • 可帶入放射線報告(原本只能帶入檢查日期) • 細菌報告帶入簽收日期(原本只有報告日期) • POMR 及duty note按新增可選擇帶入交班

  6. POMR 畫面新增異動畫面 • 目前日期以民國年呈現，維護畫面不會再 更動，列出日期會以西元年呈現 • 臨危值是由簡訊內容帶入(民國年)，需 再與檢驗科討論(待修改) • 隨時可查詢病患就診記錄,不必再跳出 • 可直接在此畫面做problem維護不必跳出

  7. POMR 畫面新增異動畫面 • 按右鍵可帶入範本

  8. 4月1日全面上線,以4月1號00：00入院病人做為切割點4月1日全面上線,以4月1號00：00入院病人做為切割點 • 3月31日前用舊的POMR,但書寫方式可改成新的方式,4月1日後全面列印新畫面

  9. 3月25日已上線醫囑新增畫面 • 1.憂鬱評量(>65歲,癌症,HIV,簽署安寧緩和意願書患者) • 2.新增查詢功能:護理病歷、護理記錄 • 3.病患明細新增高危險跌倒(高跌)查詢

  10. 3月25日上線醫囑新增畫面 住院病人在72小時內,護理人員填寫病患憂鬱評量,分數大於12分，在醫囑系統會跳出詢問是否照會精神科醫師畫面， 需要選擇照會或不照會後，此詢問畫面才不會再出現

  11. 若要照會精神科醫師，需要挑選所要照會的醫師，且填入「Brief History and Clinical Findings」，按下「確定」鍵後，即照會完成。

  12. 照會完成後，醫囑顯示畫面

  13. 新增查詢功能:護理病歷護理記錄

  14. 護理病歷

  15. 護理記錄

  16. 3月25日已上線醫囑新增畫面 • 病患明細新增高跌查詢

  17. 4月01日上線醫囑新增畫面

  18. 4月01日上線醫囑新增畫面 • 1.住院診療計劃書

  19. 4月01日上線醫囑新增畫面 • VS comment 只能由VS工號進入 • 非病人之主治醫師只能查詢 • 曾care 過此病患的VS有權限進入修改

  20. Thanks for your attention

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