1、Overview Admission Note入院录写作概述入院录写作概述杨明山Classification of Medical Writing Medical LiteratureMedical RecordAdmission NoteClassification of Medical Writing MIAs abstractIMRAD paperSystematic ReviewGeneral Medical Record (History)Admission NoteDaily RecordDischarge NoteAdmission NoteClinical RecordPOMR
2、Problem-oriented Medical RecordLawrence Weed. MD. 1947: Columbia University ？ : Yale University School of Medicine 1964: “Medical records, patient care, and medical education”Problems ListProblemNo.Active ProblemOnset DateInactive Problem Date Resolved#1 Acute peritonitis14/7 17/7#2 Cholecys-tectomyOct/70#3 hypertension controlled(Admission Note)Medical Writing Series4.20 method入院录廿句写作法Chief ComplaintSection OneChief ComplaintSection OneOnly 1 sentence
