Margolis C Z, Barak N, Vardy P, Winter S
Isr J Med Sci. 1984 Nov;20(11):1044-50.
The problem-oriented record (POR) is a medical record format that consists of a standard data base, a problem list, problem-oriented plans and problem-oriented progress notes. It has been claimed repeatedly that the use of a POR improves medical care. The effect of the standard data base and problem list components of the POR on the process of care was determined. Process of care was defined as the quantity and type of data collected and the number of problems identified per patient, which were measured before and after introduction of the POR into the pediatric wards of a regional university hospital, using a standardized audit technique. The same measures were also made in the pediatric wards of two similar hospitals at which the POR had not been introduced. Data collection scores in the experimental hospital for both subjective and objective data increased significantly both after POR implementation and also in comparison with the two other hospitals. The type of data collected was determined by the POR forms. The number of problems identified increased, but not significantly. We conclude that the standardized data base and problem list components of the POR can increase the amount and determine the type of data collected in pediatric wards, while not significantly affecting the number of problems identified.
问题导向记录（POR）是一种病历格式，由标准数据库、问题清单、问题导向计划和问题导向进展记录组成。人们多次声称使用POR可改善医疗护理。确定了POR的标准数据库和问题清单组件对护理过程的影响。护理过程被定义为收集的数据数量和类型以及每位患者识别出的问题数量，通过标准化审核技术在一家地区性大学医院的儿科病房引入POR之前和之后进行测量。在另外两家未引入POR的类似医院的儿科病房也进行了同样的测量。在实验医院，实施POR后，主观和客观数据的收集分数均显著增加，并且与另外两家医院相比也是如此。收集的数据类型由POR表格决定。识别出的问题数量有所增加，但不显著。我们得出结论，POR的标准化数据库和问题清单组件可以增加儿科病房收集的数据量并确定其类型，同时对识别出的问题数量没有显著影响。
