Problem-oriented Record Research Articles

A problem-oriented systems approach to primary care system development: development and initial testing of the problem-oriented primary care system development record

BackgroundThere is significant global policy interest related to enabling a data-driven approach for evidence-based primary care system development. This paper describes the development and initial testing of a prototype tool (the Problem-Oriented Primary Care System Development Record, or PCSDR) that enables a data-driven and contextualized approach to primary care system development.MethodsThe PCSDR is an electronic record that enables the systematic input, classification, structuring, storage, processing and analysis of different types of data related to the structure, function and performance of primary care systems over time. Data inputted into the PCSDR was coded using the WHO’s PHC-IMPACT framework and classification system. The PCSDR’s functionalities were tested by using a case study of primary care system development in Tajikistan.ResultsTajikistan’s case study demonstrated that the PCSDR is a potentially effective and conceptually-sound tool for the input, classification, structuring and storage of different data types from myriad sources. The PCSDR is therefore a basic data entry and data management system that enables query and analytics functions for health services research and evidence-based primary care system development functions.ConclusionsThe PCSDR is a data system that enables a contextualized approach to evidence-based primary care system development. It represents a coherent and effective synthesis of the fields of primary care system development and performance assessment. The PCSDR enables analysts to leverage primary care performance assessment frameworks for a broad range of functions related to health systems analysis, improvement and the development of learning health systems.

Implementation of the Format for the Nursing Problem Oriented Record (Por) Performance in Investment Health Center in Ternate City 2018

Completeness of nursing documentation is one of the quality indicators of nursing care. Based on the nursing practice law no. 38 article 37, nurses in carrying out Nursing Practices are obliged to document Nursing Care in accordance with the standards. Documentation in Inpatient PKM consisting of Siko, Jambula, and Sulamadaha PKM itself, based on the observations of researchers found several obstacles, namely, the lack of nurses given the large number of PKM programs that must be run, varying levels of education so documentation has a different understanding, this also supported by the lack of education and training related to temporary nursing care documentation relating to the Nursing Process and Documentation experiencing some recent changes. The purpose of this study was to determine the effect of applying the nursing documentation format for the model Problem-Oriented Record (POR) on the performance of nurses in the Inpatient Health Center in Ternate City. The design of this study is quasi-experimental, namely, pre and post-test without control group. The population is nurses with 41 people in PKM Inpatient who are in Ternate City. Samples were taken by total sampling technique and analyzed using statistical tests t-test, Anova, and correlation. The results of the study found a significant difference between the performance of nurses before and after the application of the documentation format for nursing care in the POR model (p-value: 0,0005 α: 0.05) while the characteristics of respondents included age, sex, marital status, length of work and education had no effect on performance.

Are You Making Yourself Clear? You Can't Communicate, or Think, Effectively If You Can't Write Clearly.

In the not too distant past, illegible handwriting was considered to be the biggest problem with medical record keeping. Now the primary problem with medical records is that they are disorganized, and usually undigested, data dumps. A solution to at least part of this problem lies in utilizing the principles of the problem-oriented record. When one contemplates the optimal format for progress notes, it is worth considering the purposes of progress notes. While progress notes do, of course, play a role in billing, the primary purposes of a progress note should be to provide efficient and effective communication with all who are caring for that patient and to facilitate efficient and effective contemplation of the condition of and the plans for that patient. Although it is beyond the scope of this treatise on creating progress notes, it is also worth pointing out that all patient care notes will also occasionally have legal implications and lawyers reading clinical notes will pay far more attention to assessments and plans than they will to data and results recorded in progress notes that are always easily available elsewhere in the patient record. In other words, lawyers reviewing medical records want to know what the clinicians caring for a patient were thinking, in addition to what those clinicians actually did for that patient. While all of these issues must be kept in mind, we will focus primarily on the role of clinical notes in providing optimal patient care, particularly in the realm of cardiothoracic surgery, though the principles to be enunciated can apply to most disciplines and to most clinical environments.

Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature.

BackgroundA problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR).Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR.MethodsOn both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements.ResultsIn this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability.ConclusionsTwo main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0341-0) contains supplementary material, which is available to authorized users.

Eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva

The understanding of adverse events may simplify the inquiry regarding the quality of nursing care, presuming a foregrounding role in evaluating health services. The aim of the study was to identify adverse events in nursing care in an intensive care unit. Data were collected using an appropriate form known as problem-oriented record (POR) over a 10-month period; patients were monitored throughout their intensive care unit stay. Over the study period, 550 adverse events were recorded as follows: 26 concerned the "five rights" related to drug administration; 23 to non-administered medication; 181 to inappropriate medication records; 28 to failure in infusion pump assembly; 17 to not performed inhalation; 8 to incorrect handling of needles and syringes; 53 to not performed nursing procedures; 46 to incorrect handling of therapeutic and diagnostic devices; 37 to alarms/warnings of devices used incorrectly; and 131 to failure in data recording by nurses. The occurrence of adverse events in the care given to patients by the nursing team are significant indicators that disclose the quality of nursing care. Therefore, these events should be analyzed to support in-service training of the nursing staff.

Teaching psychological diagnosis and management.

Teaching experiences have been described which illustrate the medical student's tendency to isolate what is learned in psychiatry from clinical work in general medicine. This tendency can be minimized by presenting diagnosis as the complete assessment of a patient, rather than exclusively as a search for disease. Early experience in patient care helps the student broaden his or her concept of clinical assessment. An important goal of psychiatric teaching in medical school is to help students learn to evaluate the psychological status of the general medical patient. Attention is focused upon this evaluation by use of the problem-orientated record. Since the data base is derived largely from the medical history, objectives for the interview are presented in detail. Students are encouraged to consider the relations between the patient's psychological status and other aspects of the medical problems. Only after they have learned to make evaluations of general medical patients, are the psychiatric syndromes introduced. An example is presented of a programme in which psychiatric teaching is carried out in a surgical ward of a general hospital. Success of such programmes depends upon explicit description of goals and methods, and upon collaboration with colleagues in other departments who share similar goals.

Using a time-saving form to document emergency assessments

Serving the patient with a dental emergency can be both challenging and rewarding. Much of the challenge comes from incorporating a new spoke into the turning wheel that is the daily schedule. With the unplanned nature of the emergency visit, the dental team must remain diligent in record keeping. This is especially true because in emergency dental care, no treatment plan has yet been established to serve as a blueprint for care. 1 Weed LL Medical records, medical education, and patient care: The problem-oriented record as a basic tool. Press of Case Western Reserve University, Cleveland1970 Google Scholar

Textual content, health problems and diagnostic codes in electronic patient records in general practice

Objective - To investigate textual content, health problems and diagnostic codes in everyday electronic patient records. Design - Retrospective and observational database study. Setting - Primary health care in Stockholm. Subjects - Twenty randomly selected general practitioners with 20 records each. Main outcome measures - The frequency of use of problem-oriented medical records. The number of words, problems and diagnostic codes. The completeness and correctness of the diagnostic codes. Results - About 14.5% of 400 studied records were problem-oriented. The mean number of words per record was 99.4, and the mean number of problems managed per record was 1.2. On average, there were 1.1 diagnostic codes per record and this differed widely among GPs and also among the electronic patient record systems. The mean number of codes per problem was 0.9, and the proportion of correct codes was 97.4%. Conclusions - The electronic patient records in general practice in Stockholm have an extensive textual content. A vast majority of the problems are coded and the completeness and correctness of diagnostic codes are high. It seems that problem-oriented electronic patient record systems enforce coding activities. It is feasible to establish a database of diagnostic data for research and health care planning based on electronic patient records.

Forensic social work: Legal aspects of professional practice : by Robert L. Barker and Douglas M. Branson The Haworth Press, Inc. (10 Alice Street, Binghamton, New York 13904-1580), 1993, 139 pp., hardcover—$26.95; softcover—$19.95.

Contents * Preface and Acknowledgments * Chapter 1. Forensic Social Work in a Litigious Society * The Purpose of Forensic Social Work * Law in the Origins of Social Work * Early Affinity of Social Work and the Law * Divergence Between Social Work and the Law * Growth of the Litigious Society * Social Work's Renewed Interest * What Social Workers Must Know About the Law * The Emergence of Forensic Social Work * Chapter 2. The Practice of Forensic Social Work * What Do Forensic Social Workers Do? * Motivations for Forensic Social Workers * Payment for Forensics Experts * Positive Incentives * Forensic Social Work As a Part-Time Occupation * Steps Toward A Forensics Specialty * How Expert Witnesses Become Established * Referral-Building Activities * Forensic Marketing Organizations * Forensic Professional Groups * Forensic Experts in Related Fields * National Organization of Forensic Social Workers * Conclusion * Chapter 3. Testifying in Courtrooms * Types of Courtroom Witnesses * Roles of the Social Work Fact Witness * Distinguishing Fact and Expert Witness * The Subpoena * Presenting Testimony Effectively * Responding to Direct Examination * Responding to Cross-Examination * Hazards in Presenting Testimony * Testifying Against Clients * The Testimony of Children * Recovered or Implanted Memory * Ten Guidelines for the Effective Witness * Chapter 4. Testifying As an Expert Witness * Pretrial Negotiations * Negotiating Payment * Preparation As an Expert Witness * Rehearsing Expert Testimony * Voir Dire: Qualifying As an Expert * Presenting Expert Testimony * Direct Examination of the Expert * Cross-Examination of Expert Witnesses * Tactics to Impeach Expert Witnesses * Conclusion * Chapter 5. Malpractice and How To Avoid It * Some Malpractice Examples * Responsibility for Therapy Outcomes * Alleged Child Abuse: To Report or Not? * The Ramona (ital.) Case * Criteria for Malpractice Liability * Preventive and Defensive Practices * Conduct Leading to Malpractice Claims * Chapter 6. When Laws and Ethics Collide * The Limits of Confidentiality * Child Abuse and Neglect Laws * The Tarasoff (ital.) Case * Rationale of Judges and Legal Officials * Guidelines for Coping * Implementing the Actual Warning * Jaffee vs. Redmond (ital.) * Conclusion * Chapter 7. Preparing for Litigation * Recognizing a Potential Legal Hazard * The Emotional Risks of Litigation * When to Seek Legal Help * Costs of Litigation * Goals in Hiring a Lawyer * Trial or Settlement? * Chapter 8. Professional Review: Judgment by Colleagues * Need for Alternatives to Law Courts * Philosophies of Reviewing Organizations * Types of Sanctions * Disciplinary Action Reporting System (DARS) * Third-Party Review Procedures * NASW Peer Review Procedure * Critique of NASW Adjudication Procedures * Other Professional Review Procedures * Inevitability of Peer Review * How To Avoid or Minimize Sanctions * When Misconduct Is Acknowledged * Chapter 9. Case Recording and Written Contracts * Report Writing for the Litigious Society * Record Keeping for Couples and Families * The Problem-Oriented (SOAP) Record * Accessibility of Case Records * Forensics Reports versus Case Records * The Written Contract * Written versus Verbal Contracts * The Preservation of Contracts and Records * Conclusion * Chapter 10. Legal and Professional Credentials * Practicing Without Credentials * Consequences of Misrepresentation * What Are Credentials? * Origins of Social Work Credentials * Requirements for Professional Credentials * Social Work Licensure * Comparing Credentials with Other Professions * Unresolved Credentialing Problems * The AASSWB Model Social Wo

Client-Focused Recording: Linking Theory and Practice

The current use and teaching of recording is explored. The development of the use of records for worker accountability and the loss of recording as part of the social work process is traced historically. An alternative to the medical model (problem-oriented record) is proposed based on a client-focused model that espouses social work values.

Linking quality assurance and quality of care.

Since the introduction of the problem-oriented record into hospital work nearly 30 years ago, psychiatry has struggled to adapt it to the complex bio-psycho-social determinants of illness and therapeutics. This struggle has been especially difficult with the seriously and persistently ill patient who requires more than a minimal hospital stay. Justification of the work with the longer-stay patient has now come under extreme pressure from utilization review, third-party payors and quality assurance, but hospital psychiatrists continue to have the same difficulties with documentation. Based on two years of chart review with clinical teams, principles of psychosocial rehabilitation and a dynamically oriented philosophy of inpatient treatment for the long-term patient, this presentation demonstrates one method for linking problems and goals with length of stay, quality assurance behaviors with quality of care, and integration of the multidisciplinary team into the entire process.

Establishing a quality improvement process for identification of psychosocial problems in a primary care practice

A quality improvement process that will significantly increase the rate of identification of psychosocial problems through routine use of case-finding instruments can be established in a general medicine practice. Two groups of patient examination reports written by physicians were retrospectively compared with the patients' responses on the case-finding database instrument. The samples were obtained by sequential selection in four time periods. The study occurred in a university general internal medicine practice that utilizes the problem-oriented record. The patients studied were seen for first-time comprehensive examinations designed to identify all important health problems, including psychosocial problems. The authors compared performances of the physicians in identification of psychosocial problems before and after the intervention, which consisted of a pilot study audit of psychosocial problem identification, establishment of standards for interpretation of the case-finding instrument, design of a flow sheet to make case-finding data clearly available to the physician at each comprehensive examination, and feedback of physician performance according to practice-adopted standards for identification of psychosocial problems. The result of the intervention was an increase in psychosocial problem identification from 67% to 90% of problems present, p less than 0.05 by chi-square distribution; or a decrease from 33% to 10% in psychosocial problems missed by the physicians. The quality improvement process for identification of psychosocial problems described in this report significantly increased the rate of identification of psychosocial problems by general internists.

Optometry in the Multidisciplinary Health Care Setting

A variety of health care delivery settings and models have been established in the 1980s. The multidisciplinary setting encourages comanagement and continuity of care, provides convenient consultation and communication, and is cost effective. It stimulates learning, helps to consolidate management strategies, and results in improved quality of care. Therefore, the patient and the provider both benefit from this environment. In 1978, the problem-oriented record keeping system (PORS) was implemented in the eye care service of a Boston neighborhood multidisciplinary health center. It facilitated learning, established guidelines for peer review, and improved patient care by assisting the eye care service to communicate patient problems to the other health center services effectively. We review the background of urban multidisciplinary health care settings and the PORS, as well as present several cases in which optometrists participated in patient comanagement with other health care specialists to develop a comprehensive management plan. The benefits of the multidisciplinary approach to both patients and providers are discussed.

New Premises and New Tools for Medical Care and Medical Education

Medical care and medical education can be supported more than in the past by using new tools and new premises for the effective linkage between bodies of knowledge and the use of that knowledge. The medical record can be converted from a source-oriented record to a problem-oriented record, enabling to trace not only what was done, but why it was done. These possibilities reveal new insights in the use of databases, problem lists, problem-oriented plans, and problem-oriented progress notes and flowsheets. It brings about a new behavior in teaching which replaces memorizing facts, new possibilities for medical care, and new responsibilities both for physicians and patients. We now have knowledge-coupling tools that can be used directly with the patients at the time of problem solving. Patients are becoming active participants in this process, bringing about new roles for experts as well as expert systems.

Clinical evaluation of foot and ankle dysfunction.

Patients with foot and ankle dysfunction require a systematic approach in the evaluation process. An outline of the procedure is provided using the problem-oriented record system as a basis. Subjective data describe the patient's feelings toward the problem and goals concerning it. Objective data encompass several areas, including a detailed history; general posture; soft tissue structures; functional capacity; and the circulatory, musculoskeletal, and neuromuscular systems. The data are reviewed, and an accurate assessment of the nature and cause(s) of the dysfunction are made. Realistic goal statements are then written to prepare for successful treatment planning.

ICD, POR, and DRG

A system of scientific classification should have a suitable basic axis of organization, standardized names, clearly specified operational criteria, and multiaxial arrangements for citing important attributes beyond those included in the basic axis. During the past century, the main nosologic system for identifying human ailments has been the International Classification of Diseases (ICD), which has a well-organized and well-accepted nomenclature, but which lacks operational criteria and an appropriate multiaxial pattern. Two new systems of classification during the past two decades are intended for other purposes and would not be satisfactory as nosologic substitutes. The Problem-Oriented Record (POR) does not have a standardized nomenclature or criteria; and the Diagnosis-Related Group (DRG) approach was organized mainly for fiscal goals. As the basic taxonomy used for classifying human ailments, the ICD needs substantial improvement to fulfill its scientific role in statistics for the occurrence and treatment of disease.

ICD, POR, and DRG. Unsolved scientific problems in the nosology of clinical medicine.

A system of scientific classification should have a suitable basic axis of organization, standardized names, clearly specified operational criteria, and multiaxial arrangements for citing important attributes beyond those included in the basic axis. During the past century, the main nosologic system for identifying human ailments has been the International Classification of Diseases (ICD), which has a well-organized and well-accepted nomenclature, but which lacks operational criteria and an appropriate multiaxial pattern. Two new systems of classification during the past two decades are intended for other purposes and would not be satisfactory as nosologic substitutes. The Problem-Oriented Record (POR) does not have a standardized nomenclature or criteria; and the Diagnosis-Related Group (DRG) approach was organized mainly for fiscal goals. As the basic taxonomy used for classifying human ailments, the ICD needs substantial improvement to fulfill its scientific role in statistics for the occurrence and treatment of disease.

Public health nursing documentation and case management through the use of flowsheets.

Anticipatory guidance, intervention, goals, outcomes, problems-how can the public health nurse (PHN) record all this and still leave work by 5:00 p.m.? The following suggestions will help in tackling the problem. Acknowledging that documentation is a significant component of nurse-client interaction, a committee of PHNs, supervisors, and program managers was formed to periodically review and update methods of documentation. When the committee was organized, the PHNs of the Department of Public Health in San Bernardino County, California were using problem-oriented recording. This entailed the use of problem-specific narrative progress notes, a problem list, a data base, and numerous assessment tools. Problem-oriented recording worked well for several years. However, it did not provide guidelines for nursing assessments or outcomes; it did not lend itself to a comprehensive quality assurance audit; and, due to its narrative format, it was much too costly for computerization. To meet today's needs, flowsheets have been developed by the committee. We feel they are useful and adaptable to future needs. Administration requested that the committee develop a method of documentation that would meet a vast array of needs. These needs mandated a case-management system that would

Physical Diagnosis

<i>Physical Diagnosis</i>, 17th edition, by John W. Burnside and Thomas J. McGlynn is the continuation of a book first published by a Dr Cabot in 1900. The contents are logically arranged; the first four chapters give an overview of history taking, physical examination, and physician-patient interrelations. The remaining chapters cover the different organ systems, from skin to nervous system. Each of these chapters is subdivided into history, anatomy, examination, and common findings. Important points are stressed by placing them in heavy print in the text and using tables liberally. Illustrations consist of clear photographs and some excellent drawings. Overall, this is a "Dr Jekyll and Mr Hyde" textbook. The "Dr Jekyll," or good, aspects are the first four chapters in which the authors lucidly and in detail discuss clinical diagnosis, decision making, probability analysis, behavior and attitudes of patients and physicians, and the problem-oriented record. These chapters are excellent, particularly

The psychologist in the Problem-Oriented Record (POR).

The psychologist in the Problem-Oriented Record (POR).