van Sluijs F J
Tijdschr Diergeneeskd. 1983 Jul 1;108(13):520-5.
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.
将以问题为导向的病历与传统的、以资料来源为导向的病历进行比较，特别涉及以下几个方面：——作为辅助治疗患者的工具；——作为辅助临床医生之间沟通的工具；——作为辅助回顾性研究的工具；——作为辅助兽医医学教育的工具。结果发现，以问题为导向的病历在各个方面都优于传统病历，尽管记录过程耗时，尤其是信息录入方面。这妨碍了其大规模应用，但引入该系统的一些元素值得考虑。诊断和治疗记录尤其如此，它们是任何类型病历的宝贵补充。
