List of main questions: generally fill in the list of main questions in form, and put it at the beginning of health records and after personal general situation; Health problems are sorted by serial number of diagnosis date.

The recorded problems generally refer to abnormal situations that have affected, are affecting or will affect personal health in the future; The contents include chronic physiological or psychological diseases, surgery, social problems, family problems, behavioral problems, economic problems, abnormal signs or laboratory test results, unexplained symptoms, risk factors or common but important problems that doctors think.

SOAP-style problem description skills

Subjective information is the chief complaint symptoms, disease history, family history and social life history provided by patients or their medical companions. The description of the above situation should try to use (or be close to) the patient's language. Objective data include the findings of doctors' physical examination, laboratory examination results, psychological and behavioral measurement results, and the attitudes and behaviors of patients observed by doctors.

Assessment of health problems: A complete assessment should include preliminary judgment, differential diagnosis of the severity of problems and prognosis judgment. The content of "evaluation" goes beyond the previous disease diagnosis, and its content can be physiological problems, psychological problems, social problems and unexplained symptoms and/or complaints.

In addition, we should pay attention to the treatment plan of the problem: the plan should include the diagnosis plan, the treatment strategy including medication and treatment methods, and the education of patients.