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