Abstract
In order improve the quality of data collection, a model of Problem Oriented Medical Record (POMR) has been introduced into our department since 1988. The aim of this work is to evaluate the impact of POMR on doctors (subjective analysis) and on clinical notes (objective analysis). For the first purpose doctors were requested to fill-up a questionnaire while for the second one 96 POMR were confronted with 105 traditional medical record. The following opinions on POMR were collected: 1) 73% of doctors is able to compile POMR correctly within 6 months; 2) a longer training is necessary; 3) it is more time consuming (81%); 4) it can help in clinical decision-making (54%); 5) in communicating among doctors (61%); 6) in clinical research (57%) and medical teaching (66%); 7) it does not cause any fragmentary valuation of the patient (62%). An improvement in compiling the different sections of POMR was observed in confront with traditional medical records: present illness 89% vs 52%; past illness 83% vs 52%; personal history 78% vs 52%; familiar history 71% vs 52%; physical examination 62% vs 52%. Even if the great majority of the users (81%) declared to be in favour of the logical structure of POMR, the quality of progress notes has not improved. This is mainly attributed to the lacking in time of doctors in a department of general surgery. A modified model of the medical record is proposed.
| Translated title of the contribution | The use of the problem oriented medical record in a department of general surgery |
|---|---|
| Original language | Italian |
| Pages (from-to) | 193-197 |
| Number of pages | 5 |
| Journal | Chirurgia |
| Volume | 3 |
| Issue number | 4 |
| Publication status | Published - 1990 |
ASJC Scopus subject areas
- Surgery