The Problem-Oriented Medical Record: Implications and Potential for Improving Patient Education

摘要

A review of the literature concerning the problem-oriented medical record (POMR) identifies sources that indicate the advantages of the POMR in improving patient education efforts. The POMR approach is a means by which the patient's records are restructured from the traditional source-oriented format to a format in which information is organized around the patient's problems. Components of a particular POMR include a defined data base, a complete problem list, plans for caring for the patient, and progress notes. The structure and organization of the POMR force recognition of the educational components of diagnostic and therapeutic efforts, emphasize patient education as a significant aspect of patient care responsibility, ensure careful documentation of educational efforts, enhance communication by focusing attention on patient problems and the common progress-recording form, emphasize integration of the description of a technical procedure into the context of the patient problem, improve decision making by focusing attention on priority problems, reduce diversity and variability of an undesirable nature among health team members, and improve health team integration. Twenty-six references.