Rationale for Problem-Oriented Records
RATIONALE FOR PROBLEM-ORIENTED RECORDS (POR)
Murray Rosenthal, DDS
August 12, 2004
HISTORY – POR has been used since the 1960s. It was developed by Dr. Lawrence Weed. It has been so successful in enhancing patient management that it was mandated by the federal government in regulations regarding community health centers.
PURPOSE – POR provides organization for the logical gathering of information and the rational establishment of treatment strategies.
SECTIONS OF POR
1. Data Base – Initial history including the chief complaint; physical examination; x-ray reports; lab reports; and other pertinent data. This leads to the development of the initial problem list.
2. Problem List – Problems can social, medical, dental, and psychiatric in nature. The problems listed are diagnoses and symptoms, physiological findings, abnormal lab and x-ray results. Problems are listed by number. This list is dynamic and is continually changing and expanding. Separate problem lists are maintained for chronic disorders, acute disorders, family conditions, and any other list one desires. The problem list is placed in the front of the chart because of its importance.
3. The Initial Plan – the initial plan is related to each problem on the list. The plan is both therapeutic and educational.
4. The progress Note – This is also problem oriented. Each entry is listed by the number of the problem for ease of access and review. The entry is written as follows:
- Subjective – The history of the problem. It has been found that 60 to 75 percent of medical conditions can be diagnosed through the patient’s history.
- Objective – Physical findings: clinical review; lab results; x-ray results.
- Plan – Prescribed therapy and medication.
1. Table of Contents – Serves to organize the problems and to allow rapid access to the progress notes.
2. Patient Profile -- To assist provider in reviewing the needs of patients and to assist other providers in obtaining a rapid understanding of the patient.
1. Table of Contents – First place the known diagnoses. For unknown diagnoses, list the symptoms and abnormal lab and x-ray results and give each a number. Once the diagnosis is known, the symptoms and abnormal findings are crossed but the numbers are kept. This is to maintain the connection between the progress notes and the problem list.
2. Patient Profile – The problem with much medical and dental care is that we do not look at the entire patient and often mistreat. The problem list facilitates this thorough review of each patient just through the ease of looking at a list. Plato’s Triad of Learning forms the basis for all learning. As clinicians, we are in the constant process of learning about each of our patients.
Cognitive (knowledge)-------Affective (abstraction)--------Conative (action)
DENTAL – I recommend the following:
1. Listing each major diagnosis on the chronic problem list for caries, gingivitis, periodontitis, TMD, stomatological problems such as canker sores and herpes, and other problems. These should be listed by a number preceded by the letter “D” to distinguish a dental problem.
5/30/07entist should write notes in the medical progress notes listed by the number on the problem list. Conversely, the medical provider should write notes in the dental progress notes as needed particularly in response to the dentist’s notes.