Problem-Oriented Medical Record: A Real Advantage in Clinical Practice?

Abstract

In a country such as Italy, where verification of records is not customary, it may seem pointless to speak of the problem-oriented medical record (POMR). Other countries, such as the United States, consider free access to medical information to be the duty and prerogative of health administrators, legal officers, and, of course, other physicians. For this reason, medical record (MR) must be efficient and comprehensible not only to the physicians who compile it (which is not always the case) but also to physicians from other institutions and departments, administrators, legal officers, and the patients themselves.