The problem-oriented medical record is compared with the classical, source-oriented record, with special reference to the following aspects: --as an aid in the treatment of patients; --as an aid in the communication between clinicians; --as an aid in retrospective studies; --as an aid in veterinary medical education. The problem-oriented medical record is found to be superior to the classical record in every aspect, though keeping records is time-consuming, which holds good particularly for the input of information. This interferes with large-scale acceptance, but introducing some elements of the system is worth considering. This is particularly true of the diagnostic and therapeutic scripts, which constitute a valuable addition to any type of medical record.
AbstractThe problem-oriented medical record is compared with the classical, source-oriented record, with special reference to the following aspects: --as an aid in the treatment of patients; --as an aid in the communication between clinicians; --as an aid in retrospective studies; --as an aid in veterinary medical education. The problem-oriented medical record is found to be superior to the classical record in every aspect, though keeping records is time-consuming, which holds good particularly for the input of information. This interferes with large-scale acceptance, but introducing some elements of the system is worth considering. This is particularly true of the diagnostic and therapeutic scripts, which constitute a valuable addition to any type of medical record.