Personal health records are frequently used in general medical care and have the highest value. The actual situation of family health records and the forms of establishment and use vary. However, general medical practice takes into account the care of the family unit, which is a specialty of general medicine, so recording family information is a must. At present, community health records are not given more unified requirements in general medical services. They are mainly used to assess doctors’ understanding of the health status and community resources of residents in their communities, and to assess the role of general practitioners in patient care. point of view. The problem-oriented health record recording method (problem oriented medical record, pomr) was first proposed by Weed et al. in the United States in 1968, which requires doctors to use individual health problem-oriented recording methods in medical services. The advantages are: individual health issues are concise, focused, well organized, and easy for computer data processing and management. It has now become the basic method for establishing resident health records in many countries and regions around the world. The pomr recording method generally includes basic information about the individual and his or her family, a catalog of health problems and descriptions of the problems, problem progress, flow charts, etc. Community health service personnel must fill in the form carefully in accordance with the format requirements. (1) Contents of personal health records: mainly include: 1. Basic personal information of the patient. ① Demographic information: such as age, gender, education level, occupation, marriage, race, socioeconomic status, ID number, etc. ②Health behavior information: such as smoking, drinking, including habits, exercise, medical treatment behavior, etc. ③Clinical data: past history, family history, basic biological data, preventive medicine data (immunization and periodic health examination records), psychological assessment, behavior and other data. 2. Directory of health problems. It is the main content of the health record. The recorded content is the problems that have affected, are affecting or will affect the individual's health in the past. It can be a clear or unclear diagnosis, unexplained symptoms, signs or laboratory test results. , or it can be social, economic, psychological, behavioral problems (such as unemployment, widowhood, deviant behavior, etc.). Health problems are divided into major problems and temporary problems. If time does not allow, you can only list the main health problems, and put the temporary problems in the soap daily medical record, and ask the doctor to make regular summaries. 3. Disease flow chart. It is a summary of the progress of a major problem within a certain period of time. It generally reflects the dynamic change process of some important indicators related to the problem, such as chief complaints, symptoms, physiological and biochemical indicators, some special examination results, and medication methods. , drug side effects, dietary treatments, behavioral and lifestyle changes, and psychological test results, etc. The disease flow chart is mainly used for observation and treatment records of chronic diseases and some special diseases. It is not necessary for all health problems. The items recorded in the flow chart for different types of diseases can also be different. 4. Problem description and progress record. It is the core part of pomr and is a detailed record of each patient's medical visit. First, list the individual's main health problems into a main problem catalog, and then describe each problem in the problem catalog in the form of soap. s: The patient's subjective data (subjective data) is the chief complaint, symptoms, disease history, family history, social life history, etc. provided by the patient. It should be recorded according to the patient's statement as much as possible. o: Objective data, which records the data observed by medical staff during the diagnosis and treatment process, including physical signs, laboratory examinations, X-ray diagnosis, and patients' psychological and behavioral test results, etc. a: Assessment of health problems is a key part of problem description. A complete assessment should include diagnosis, differential diagnosis, relationship with other problems, severity of the problem and prognosis, etc. This kind of assessment is different from a disease-centered diagnosis, which can be about illness, psychological problems or social problems, or unexplained symptoms or complaints. If the problem arises from a combination of multiple symptoms, discomforts, or related examination data, a final biological diagnosis may not be made due to the disappearance of the symptoms or discomforts. p: The problem treatment plan (plan) is the diagnosis, treatment, prevention, health care, rehabilitation and health education plan proposed for each problem. 5. Periodic health check-ups are early detection and early diagnosis health check-up items designed for individuals of different ages, genders, and health risk factors using a formatted health check list. Periodic health check-up plans are mainly developed during individual opportunistic medical visits or doctor's home visits. 6. Transfer consultation and hospitalization records. One of the important tasks of family medicine is to use all necessary medical and social resources to serve patients. Referral is one of the ways for family doctors to communicate with their colleagues and utilize other medical resources. The patient's referral destination can be to other primary care doctors, specialists, nurses, therapists, social workers, etc., which will be determined by the family doctor based on the patient's specific situation. Referral recording in general practice is a two-way street. 7. Preventive records. Preventive medicine services in general medicine include periodic health examinations, vaccinations, health education, risk factor screening, etc., with the purpose of early detection of patients and risk factors and intervention. Among them, periodic health examinations are an important measure that reflects preventive services in primary care abroad.

In our country, currently only children's planned immunization projects and some children's health care and women's health care projects are standardized, and other service contents have not yet been unified. General practitioners can try to set up preventive medicine service projects suitable for the needs of residents in this community based on the specific conditions of patients in this community. 8. Follow-up records for patients with chronic diseases. The follow-up records of chronic diseases such as hypertension and diabetes are filled in specially designed forms. The patient's symptoms, signs, laboratory tests, comorbidities and medication status are recorded in chronological order, the purpose of the referral and the treatment situation, health education guidance and Implementation progress and effect evaluation. 9. Laboratory and auxiliary inspection records. Content is based on the patient's health status. It can also be designed as a form, and the inspection results can be filled in at any time to avoid the file being too thick. (2) Contents of the family health file: including basic information of the family, family tree, family assessment information, directory of major family problems, problem descriptions and personal health files of each family member (the form and content are the same as the personal health file). (3) Contents of community health records: mainly include: 1. Basic community information. Including the natural environment conditions of the community, such as the geographical location, scope, natural climate and environmental conditions of the community, sanitation facilities and sanitary conditions, etc.; the demographic characteristics of the community, such as the total number of people in the community, age and gender composition (population pyramid), birth rate, Mortality rate, natural population growth rate, racial characteristics, fertility concepts, etc.; the humanistic and social environmental conditions of the community, such as the education level of community residents, religion and traditional customs, consumption level and awareness, the development and role of social groups, and family structure , marital status, family functions, public order, etc.; the economic and organizational status of the community, etc. 2. Community health resources. Including community health service agencies and health human resources status. 3. The status of community health services. Including statistics on outpatient volume, outpatient service volume, outpatient service content, classification of patients’ reasons for visiting, classification and composition of common health problems, health service utilization, referral disease types and referral rate and appropriateness analysis, etc. within a certain period of time. 4. The health status of the community.