2015/7/8

6935211

415

151

185

14

416

194

50

80

14

dr.kenta.sato@gmail.com

55

104

20135
450110

1073044

199 2

1999
2005
2007

2011

HP http://www.min-iren.gr.jp/ikei-gakusei/igakusei/zi5_medi/2011/049/mw-ken-49.html
HP http://www.chidoribashi-hp.or.jp/chidoribashi-hph/index.html

ICT
WHO

2015/7/8

Family phisician

Hospitalist

CHFCOPDLCCKD

1
11
2
12
3
13
4
14
5 15
6
16
7
17
8
18
9 19
10
20
20

2015/7/8

Community-oriented medical education

/
/
/

MNA-SF

Common problem

FGI

% %
19/
17.81.8

2600032000
6500/

MET

M&M




NSTICTACLS

2015/7/8

SOAP

SOAP
S

SO
SO

etc

Pronlem oriented system

A

P

SOAP

7%

38%

55%

SO
AP

2015/7/8

etc

Subjective

or

(OPQRST)

Review of Systems

Review of systems

2015/7/8

General appearance
First impressionABCD
Vital signs

Objective

Head to Toe

General appearance

Ns

Pertinent
Pertinent positive
Pertinent negative
Non-pertinent positive
Non-pertinent negative

Jolt
Kernig

Non-pertinent
Pertinent negative

General appearance
A
BRR SpO2
CBP PR
DJCS GCS
EBT

HEENT
Chest
Abd
Ext

Neuro.
Vasc.

Xp
CT
MRI

General appearance
JCS0BP9456PR96RR26SpO2 92%R/ABT36.8

S3(+)(-)
(-)(-)(-)
(+)

BUN20.1Cr1.23T
PVCHR90V1-4ST
XpCTR55

2015/7/8

POS

Problem list

SOAP

SO

1
2
Semantic qualifier : SQ

7/10

#1.

(-)(-)
(-)
CKD
ACE-I

#2.

S3(+)
TV1-4ST

#3.

#1.
#2.
#3.

#a.
#b.
#c.

41

2015/7/8

Semantic Qualifier

#1. 14.4.20
MCV7014.4.20SQ)
514.4.22SQ)
CF14.4.26
14.4.30
cStageT3N2M114.5.3
PS4PPS14.8.24

#1.

SQ)

#1.100Nohria4

#
#
#

Post PCIDESHFrEFCHF stageC

#2.
#1

# # #1.#a.

123
abc

2015/7/8

Brief summary

SO

Assessment

Brief summary

Opening statement

SO

PertinentSQ

30

STT

definite
probable
possible
less likely
unlikely
ruled out

%
89
56
23

SO

#1.
Brief summary

SO

SOAP

Probable
Less likely
Ruled out

AP

2015/7/8

Assessment

Plan

52319

Plan

Tx

Dx

Ex

Px

Air way
Breathing
Circuration
Dysfunction of CNS
Environment
Infection P&C
Insulin & Nutrition
Ion & fluid
Rest or Rehabilitation

ABG
Blood
CXR
Dextor
ECG
FAST & FEER
Gram

Tx

Dx

Ex

Px

10

2015/7/8

SOAP

http://www.igaku-shoin.co.jp/paperDetail.do?id=PA02985_05

C..

SpO2Crackle

PSICHADS2

11