骨科標準病歷範本-POMR
一、【POMR 範本】Femoral shaft fracture
2011/01/11 10:30 AM
Post-op day
S: Op wound pain improving
O:Vital sign: T/P/R/BP
General appearance: smooth/fair/weak
Chest: symmetric/asymmetric
:breath: smooth/SOB/wheezing; with room air/cannula/ventri mask
:heart sound: RHB/ murmur grade
Abdomen: soft/hard, flat/distended
: bowel sound: times/min
: defecation:smooth ;bloody/tarry stool
left thigh : w’d: dry/oozing with clean/serosanguinous/pus-like discharge
local heat: erythmatous change: swelling:
distal leg: motor/sensory function
:dorsalis pedis a./post. Tibial a. pulse:
Problem #1:Left femoral shaft fracture s/p ORIF with interlocking nail
A: Left femoral shaft fracture s/p ORIF with interlocking nail. Wound pain improving
Plan:Wound care with (BI solution or wet dressing Q?H )
Keep antibiotics use for ? day
Ice packing
Pain control
Rehabilitation with walker, partial weight bearing
二、【POMR 範本】THR
2011/01/11 10:30 AM
Post-op day
S: Op wound pain improving
O:Vital sign: T/P/R/BP
General appearance: smooth/fair/weak
Chest: symmetric/asymmetric
:breath: smooth/SOB/wheezing; with room air/cannula/ventri mask
:heart sound: RHB/ murmur grade
Abdomen:soft/hard, flat/distended
:bowel sound: times/min
: defecation:smooth ;bloody/tarry stool
pillow between two legs to prevent leg over-adduction
: w’d: dry/oozing with clean/serosanguinous/pus-like discharge
local heat: erythmatous change: swelling:
:hemovac/penrose tube: ml/day
distal leg: motor/sensory function
:dorsalis pedis a./post. Tibial a. pulse:
Problem #1: Left hip advance OA s/p THR
A:Left hip advance OA s/p THR. Wound pain improving
Plan: Wound care with (BI solution or wet dressing Q?H )
Keep antibiotics use for ? day
Ice packing
Pain control
Rehabilitation with walker, partial weight bearing
三、【POMR 範本】Femoral neck fracture
2011/01/11 10:30 AM
Post-op day
S: Op wound pain improving
O:Vital sign: T/P/R/BP
General appearance: smooth/fair/weak
Chest: symmetric/asymmetric
:breath: smooth/SOB/wheezing; with room air/cannula/ventri mask
:heart sound: RHB/ murmur grade
Abdomen: soft/hard, flat/distended
: bowel sound: times/min
: defecation:smooth ;bloody/tarry stool
: w’d: dry/oozing with clean/serosanguinous/pus-like discharge
local heat: erythmatous change: swelling:
:hemovac/penrose tube: ml/day
distal leg: motor/sensory function
:dorsalis pedis a./post. Tibial a. pulse:
Problem #1:Left femoral neck fracture s/p ORIF with cannulated screws
A:Left femoral neck fracture s/p ORIF with cannulated screws. Wound pain
improving
Plan: Wound care with (BI solution or wet dressing Q?H )
Keep antibiotics use for ? day
Ice packing
Pain control
Rehabilitation with walker, partial weight bearing
四、【POMR 範本】Shoulder scope
2011/01/11 10:30 AM
Post-op day
S: Op wound pain improving
O: Vital sign: T/P/R: BP: mmHg
General appearance: smooth
Chest: symmetric/asymmetric
:breathing sound: clear /wheezing;
with room air/cannula/ventri mask support
:heart sound: RHB/ murmur grade
Abdomen:soft/hard, flat/distended
:bowel sound: normoactive/ hypoactive
R’t / L’t shoulder: sling protection
Wound: clear/ mild oozing
tenderness/ swelling
no local heat / no erythema
ROM: forward elevation
abduction
distal motion / sensation:
distal pulsation:
Problem #1:R’t / L’t shoulder impingement syndrome/ rotator cuff tear/ SLAP lesion/
Bankart lesion
A:Post-op wound pain with mild wound swelling
Plan: Wound care
Sling protection
Rehabilitation
Ice packing
Non-weight bearing of right / left upper limb
五、【POMR 範本】Tibial plateau
2011/01/11 10:30 AM
Post Op Day 1
S: Post-op wound pain improving
O: vital sign: T/P/R:37.0 (°C) / 72bpm / 16bpm
Bp: 130/80 mmHg
Consciousness: clear GCS E4V5M6
Chest: clear breathing sound
Abdomen: soft, no tenderness
Active bowel sound, flatus passage (+)
Urine output : 1500ml. clear
Hemovac drainage: 60ml, bloody
Wound: clear and dry, mild swelling
Distal sensory status: intact
Pulsation: of dorsalis pedis:++
Skin color: normal
Toe flexion and extension: full
Problem #1:right side tibial plateau fracture, Schatzker III s/p ORIF with buttress plate fixation, long leg cast protection was applied after surgery
A: post op wound pain with mild wound swelling
P: Antibiotic prophylaxis
Pain control and wound care
Close checks signs of 5”P” to prevent compartment syndrome
Early rehabilitation
六、【POMR 範本】Spine
2011/01/11 10:30 AM
Post Op Day 1
S: Back operation wound pain. No stool passage for 3 days
O: vital sign: TPR BP
No dyspnea
Breathing sound: coarse
Neurological examination and specific finding
1 pain and numbness distribution
dermatone
lower bck pain >or < lower leg radiation pain
2 muscle power
quadriceps r,t l.t
EHL r,t l,t
FHL r,t l.t
3 reflexs
knee r,t l.t
ankle r,t l,t
4 anal tone and spincter function
Wound condition: no bleeding, no discharge, dry
Problem #1:Spine stenosis s/p operation (Laminectom+Disectomy)
A: Spine stenosis s/p operation (Laminectom+Disectomy), wound pain, moderate
Plan: Wound care
Pain control: panadol 1 # po QID, demoral 50mg Q4H prn
Consult rehab. Physician for opinions on further tx
Problem #2: Constipation
A: Constipation, settled with operation, bed rest, medication and modified diet
Plan: Maintain the prescription
Emphasize the importance of high fiber diets and adequatefluid intake for
normal bowel function
七、【POMR 範本】Ankle fracture
2011/01/11 10:30 AM
Post-op day
S:Post-op wound pain improving
O:Vital sign: T/P/R/BP
General appearance: smooth/fair/weak
Chest: symmetric/asymmetric
:breath: smooth/SOB/wheezing; with room air/cannula/ventri mask
:heart sound: RHB/ murmur grade
Abdomen:soft/hard, flat/distended
:bowel sound: times/min
: defecation:smooth ;bloody/tarry stool
R’t/L’t ankle: protected with short leg cast/splint/brace
: w’d: dry/oozing with clean/serosanguinous/pus-like discharge
local heat: erythmatous change: swelling:
:hemovac/penrose tube: ml/day
:ROM:dorsal/plantar flexion
:external/internal rotation
distal leg: motor/sensory function
:dorsalis pedis a./post. Tibial a. pulse:
Problem #1:L’t malleolar fx s/p operation
A: L’t malleolar fx s/p op. Post-op wound mild swellingand erythematous change
Plan: Wound care with (BI solution or wet dressing Q?H )
Keep antibiotics use for ? day
Ice packing
Pending for report (culture/lab.)
八、【POMR 範本】Distal radius fracture
2011/01/11 10:30 AM
Post-op day
S:Post-op wound pain improving
O: Vital sign: T/P/R
General appearance: smooth
Chest: symmetric/asymmetric
:breathing sound: clear /wheezing;
with room air/cannula/ventri mask support
:heart sound: RHB/ murmur grade
Abdomen:soft/hard, flat/distended
:bowel sound: normoactive/ hypoactive
R’t / L’t wrist: Wound: clear/ mild oozing
tenderness/ swelling
no local heat / no erythema
Finger ROM: Thumb extension
Thumb abduction
Finger apposition
distal motion / sensation:
distal pulsation:
Problem #1:Left distal radius fracture s/p ORIF
A:Left distal radius fracture s/p ORIF, post OP day 3. Post-op wound mild swelling
and erythematous change
Plan: Wound care
Splint protection
Rehabilitation
Ice packing
Elevation of injured extremity