Problem-oriented medical record
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In medical records, a Problem-oriented medical record is defined as "A system of record keeping in which a list of the patient's problems is made and all history, physical findings, laboratory data, etc. pertinent to each problem are placed under that heading."[1]
The concept was introduced in 1968 by Larry Weed[2][3].
Maintainance of problem lists have been proposed to be a responsibility of healthcare providers[4].
Problem lists may be incomplete[5]. Incomplete problem lists can harm medical care[6] and patients[7].
See also
External links
References
- ↑ Anonymous (2024), Problem-oriented medical record (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Weed LL (1968). "Medical records that guide and teach". N Engl J Med. 278 (11): 593–600. doi:10.1056/NEJM196803142781105. PMID 5637758.
- ↑ Weed LL (1968). "Medical records that guide and teach". N Engl J Med. 278 (12): 652-7 concl. doi:10.1056/NEJM196803212781204. PMID 5637250.
- ↑ Sittig DF, Singh H (2012). "Rights and responsibilities of users of electronic health records". CMAJ. 184 (13): 1479–83. doi:10.1503/cmaj.111599. PMC 3447016. PMID 22331971.
- ↑ Blecker S, Katz SD, Horwitz LI, Kuperman G, Park H, Gold A; et al. (2016). "Comparison of Approaches for Heart Failure Case Identification From Electronic Health Record Data". JAMA Cardiol. 1 (9): 1014–1020. doi:10.1001/jamacardio.2016.3236. PMC 5289894. PMID 27706470.
- ↑ Samal L, Linder JA, Bates DW, Wright A (2014). "Electronic problem list documentation of chronic kidney disease and quality of care". BMC Nephrol. 15: 70. doi:10.1186/1471-2369-15-70. PMC 4021481. PMID 24885821.
- ↑ Gandhi TK, Zuccotti G, Lee TH (2011). "Incomplete care--on the trail of flaws in the system". N Engl J Med. 365 (6): 486–8. doi:10.1056/NEJMp1106313. PMID 21830964.