Kim C. Problem-Oriented Medical Record in Electronic Healthcare System...2024

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Kim C. Problem-Oriented Medical Record in Electronic Healthcare System...2024

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Textbook in PDF format The medical record is a systematic documentation of a patient’s medical history and care over time, written by healthcare providers. It is a fundamental part of a clinician’s duty to provide optimal patient care, which includes taking various types of notes. These notes consist of clinical fndings, decisions made, diagnostic workup, information provided to patients, agreed-upon actions, prescribed medications, surgical procedures, and treatment outcomes. These processes should be summarized in a sequence Preface Patient Medical Record History and Evolution of Medical Records Formats and Types of Medical Records Components of Current Medical Records Functions of Medical Records Clinical Reasoning for Diagnosis and Treatment Gathering Information from the Patient History Taking Box 2.1 Main Categories of History TakingDuring the Medical Interview Physical Examination Laboratory Findings Analyzing the Information Making a Diagnosis Planning and Implementing Treatment Evaluating the Results of Treatment Impression Versus Problem in Making a Diagnosis Pitfalls in Making Impressions Problems Based on a Data Set Components of the Problem-Oriented Medical Record (POMR): The Legacy of Lawrence Weed The Database The Problem List The Initial Plan The Progress Notes The Problem-Oriented Medical Record (POMR) for Inpatients Admission Note Initial Database Initial Problems Initial Plans Progress Note Problem List Discharge Summary The Problem-Oriented Medical Record (POMR) for Outpatients Problem List The First Visit Initial Database Initial Problems Initial Plans Follow-Up Visits The Problem-Oriented Medical Record (POMR) in the Age of Electronic Health Records Log-In Patient Selection Data Input Admission Notes Progress Notes Discharge Summaries The First Visit Note for Outpatients Follow-Up Visit Notes for Outpatients The Problem List Artificial Intelligence for Medical Records Voice Recognition-Based Electronic Health Records Note-Taking and Documentation Patient Engagement and Communication AI for Clinical Reasoning Appendix A: An Inpatient with Generalized Edema Appendix B: An Outpatient with Dry Eyes Appendix C: Layouts for POMRs Further Reading Index