problem-oriented record

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Problem-Oriented Record

an approach to patient care record keeping that focuses on the patient's specific health problems requiring immediate attention, and the structuring of a cooperative health care plan designed to cope with the identified problems. In contrast to the traditional “diary” method of record keeping organized according to the source of information (such as a physician or nurse), the POR uses progress sheets that integrate all written notes under labeled problems. Called also Problem-Oriented Medical Record (POMR).

This system of record keeping was first introduced in the late 1960's by Dr. Lawrence L. Weed for the purpose of improving patient care through systematic analysis and logical documentation of the care rendered by various members of the health care team. When properly implemented, the approach should provide a more effective means of communication among the members of the health care team (including the patient), and facilitate coordination of preventive care, health maintenance, and continuity of care. Other areas affected by the POR include cost of health care delivery, evaluation and control of quality of care rendered, and medical-legal aspects related to informed consent by the patient.

By eliminating much of the duplication of time and effort spent by health care professionals in acquiring and recording patient care data, this system can reduce significantly the overall cost of health care. Other costs related to the preparation of insurance forms, record reviews for quality control, and duplication of patient records can be reduced substantially by the more efficient and less cumbersome problem-oriented system. The accumulation of specific and objective data relative to patient care is a major step toward the establishment of explicit criteria against which the performance of health care providers can be measured. The objective evaluation of performance is especially important in the certification and recertification of health care personnel.

Although the details of implementing a POR system may vary according to the setting in which it is to be used and the type of clientele being served, there are four components that are basic to the problem-oriented record. These are the database, problem list, plan, and notes.
The Database. In the traditional system of recording, pertinent information about the patient's history and present status is scattered throughout the patient's chart. The POR system contains only one database section in which input from a variety of sources is recorded. The information recorded in the database section pertains to the particular patient in the particular setting, that is, hospital, outpatient clinic, or other health care setting, and includes his general history, physical examination findings, physiologic and laboratory data, nursing history, and observations about lifestyle and current status. Data are acquired for the purpose of identifying current (active) major problems, which are flagged in the database and then described under a titled Notes section. Minor and inactive problems are described within the database.

As time goes on, the acquisition of new information about the patient requires additional notes on the database forms. In the event such additions become extensive, the original database form may be “retired” to an inactive record and a new database generated for the active record. The active database serves as a concise and relevant record of the patient's current status, and thus facilitates continuity of care and coordination of plans for his care as he moves through various inpatient and outpatient agencies and institutions.

The patient's contribution to the database usually involves the completion of any of a number of forms designed to elicit information about his personal and family medical history. The patient accepts responsibility for answering the questions presented as accurately as possible; however, he may need assistance in completing the forms so as to avoid trivial and “false-positive” clues to the exact nature of his problems.

The database and the more extensive data about his major problems constitute the “complete data set,” that is, a complete work-up.
The Problem List. The active problem list contains those major problems currently needing attention for further observation, diagnosis, management, or patient education. It serves as the basis for a plan of care. The problems may fall into the area of psychologic, social, and economic factors, as well as the more familiar physical diagnosis. For example, the problem identified could be congestive heart failure, if this has been established previously as a documented diagnosis, or it may be only a symptom, an abnormal laboratory finding, a risk factor, or some other problem that must be dealt with. As problems are resolved or new problems added, the problem list may be retired to an inactive record and a new list prepared.

The problem list is the first document encountered in the patient's chart. It serves as a guide to the current and important health problems of the patient. Its purpose is to draw attention to the problem areas so that they will not be overlooked. In order for the problem list to serve the purpose for which it is intended, it is necessary to use language that is concise and explicit. If a diagnosis has been made, that should be written, but if there are several manifestations of an illness, they should be incorporated into a single definition that is as brief and accurate as possible. The manifestations themselves may be listed separately on a flow sheet or narrative notes elsewhere in the chart. It is important to remember that the problem list is just that, a list, and not a detailed explanation of the difficulties the patient is experiencing.
The Plan. This is a plan of action that is derived from the problems which have been identified and that serves as a focus for patient care. The written plan is entered on the progress notes under each labeled problem. Specific physicians' plans and nursing plans should be integrated to avoid duplication and to provide a means of coordinating and communicating the care plan. The physician-generated plans are those related to diagnostic studies and therapy, the traditional physician's “orders.” The nurse-generated plans are concerned with observations, interventions, diet, and patient education.

The plan as recorded in the problem-oriented record is intended to eliminate the unnecessary writing of trivia and is focused on the reporting of exceptional and relevant information only. Routine procedures and data such as the daily bath, respiratory rate, and bowel movements can be deleted from the permanent record if they are not related to the patient's problems. They may be entered on work sheets that are discarded at the time of discharge. Should an abnormality or difficulty in carrying out routine care be detected, it is entered as a problem on the problem list.
Notes. In the problem-oriented approach there is only one section for progress notes. Physicians, nurses, and all other health care personnel directly participating in the care of the patient use the progress notes to document their observations, assessments, nursing care plans, physician's orders, and so on. As a device for conceptualizing the process of recording progress notes, Weed and others suggest the soap structuring of notes: S stands for subjective data obtained from the patient and his significant others; O stands for objective data obtained by observation, physical examination, diagnostic studies, and so on; A stands for assessment of the patient's status through analysis of the problem, possible interaction of problems, and changes in status of problems; and P stands for plan. Progress notes need not be daily records of each problem. It usually is not necessary to record every problem every day, and all four components of soap need not be written daily. The goal of problem-oriented recording is to keep writing at a minimum and record only what is relevant to the patient's problems and important to communication and continuity of care.

prob·lem-·o·ri·ent·ed rec·ord (POR),

a system of record keeping in which a list of the patient's problems is made and all history, physical findings, and laboratory data, and other factors pertinent to each problem are placed under that heading; especially useful for outpatient records of patients with multiple problems who are observed during long-term follow-up.

prob·lem-o·ri·ent·ed re·cord

(POR) (problĕm-ōrē-ĕn-tĕd rekŏrd)
System of record keeping in which a list of patient's problems is made and all history, physical findings, and laboratory data, and other factors pertinent to each problem are placed under that heading.
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