problem-oriented record

record /rec·ord/ (rek´erd)

1. a permanent or long-lasting account of something (as on film, in writing, etc.).

2. in dentistry, a registration.

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problem-oriented record  (POR) a method of patient care record keeping that focuses on specific health care problems and a cooperative health care plan designed to cope with the identified problems. The components of the POR are: data base, which contains information required for each patient regardless of diagnosis or presenting problems; problem list, which contains the major problems currently needing attention; plan, which specifies what is to be done with regard to each problem; progress notes, which document the observations, assessments, nursing care plans, physician's orders, etc., of all health care personnel directly involved in the care of the patient. See also SOAP.

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prob·lem-o·ri·ent·ed record (prblm-ôr-ntd)

n. Abbr. POR

A system of record keeping in which a list of the patient's problems is created and relevant medical history, physical findings, laboratory data, medications, and treatments are listed under the appropriate medical problem.