Tryon A F, Mann W V, DeJong N
J Dent Educ. 1976 Sep;40(9):601-8.
This paper describes how the concepts and methods of problem-orientation have been applied in the clinical education of dental students. It makes the point that the problem-oriented dental record is only one part of a complete system which has five interrelated components. The problem-oriented dental record is discussed in detail, and the paper includes examples of all four sections of the record. All sections of the record are interrelated, and the steps in identifying and resolving problems follow a logical sequence: (1) collect the data base, (2) write the cue list, (3) write the problem list, (4) write the initial plan, (5) write the final plan, and (6) record progress. The problem-oriented dental record is seen as a tool for patient care, audit, and education. The main advantage lies in the way information is organized and recorded. The record is highly communicative and permits everyone involved an opportunity to relate the data collected to the problem list and to the decisions made regarding how problems will be resolved. The record and the systems were borrowed from Weed and are being adapted for use in dentistry. Although still in the trial stages, this system has proven to have many more advantages than other record-keeping systems and is invaluable as a tool for education. In the future we plan to use computers to help store and retrieve data from these records. We anticipate that a dental education built on this record will have a lasting impact on the graduates' approach to patient care. This should result in a graduate who is conversant with medical colleagues and systematic in the collection of data, listing of problems, and resolution of patient problems. Finally, we believe that the problem-oriented dental record is also a good tool to help the dental graduate become more empathetic with patients and more aware of their total health needs. The record provides a mechanism for recording physical and emotional information as well as the oral status.
本文描述了以问题为导向的理念和方法如何应用于牙科学生的临床教育。文中指出，以问题为导向的牙科病历只是一个完整系统的一部分，该系统有五个相互关联的组成部分。本文详细讨论了以问题为导向的牙科病历，并给出了病历所有四个部分的示例。病历的所有部分都是相互关联的，识别和解决问题的步骤遵循逻辑顺序：（1）收集数据库，（2）编写提示清单，（3）编写问题清单，（4）编写初始计划，（5）编写最终计划，以及（6）记录进展情况。以问题为导向的牙科病历被视为患者护理、审计和教育的工具。其主要优势在于信息的组织和记录方式。该病历具有很强的沟通性，使每个相关人员都有机会将收集到的数据与问题清单以及关于如何解决问题所做的决定联系起来。该病历和系统借鉴了威德（Weed）的模式，并正在被改编用于牙科领域。尽管仍处于试验阶段，但该系统已证明比其他记录保存系统具有更多优势，并且作为教育工具非常宝贵。未来，我们计划使用计算机来帮助存储和检索这些病历中的数据。我们预计，基于这种病历的牙科教育将对毕业生的患者护理方法产生持久影响。这应该会培养出一位能与医学同事顺畅交流、在收集数据、列出问题以及解决患者问题方面有条不紊的毕业生。最后，我们认为以问题为导向的牙科病历也是一个很好的工具，有助于牙科毕业生对患者更具同理心，并更了解患者的整体健康需求。该病历提供了一种记录身体和情感信息以及口腔状况的机制。
