Margolis C Z
Paediatrician. 1979;8(3):152-62.
After 10 years of experience using the problem-oriented record (POR), Weed proposed that both patient care and clinical education could be improved by changing traditional medical records to a problem-oriented format. The problem-oriented system of record keeping has since been attempted or adopted by many physicians in the United States and abroad. This article will review four aspects of the POR. First, it will define the format of the POR in an ambulatory and ward setting. Second, it will discuss POR implementation. Third, it will attempt to assess the extent to which POR is in use currently. Fourth, it will review the studies that have attempted to evaluate the effectiveness of the POR.
在使用问题导向记录(POR)十年之后,威德提出,将传统病历改为问题导向格式可以改善患者护理和临床教育。此后,美国和国外的许多医生都尝试或采用了问题导向的记录保存系统。本文将回顾问题导向记录的四个方面。首先,它将定义门诊和病房环境中问题导向记录的格式。其次,将讨论问题导向记录的实施情况。第三,将尝试评估问题导向记录目前的使用程度。第四,将回顾那些试图评估问题导向记录有效性的研究。