PMID: 8591178Jan 1, 1995Paper

Health record problem-oriented information system

Medinfo
J RomeuA Ortiz

Abstract

Health Record refers to the recording of the medical and relevant social history of the patient, obtained directly or indirectly. It is an instrument of frequent use that must guarantee the quality of assistance provided, reflecting all information pertinent to forming the patient's medical history. It must be designed so that data is easily and effectively retrieved for everyday use, without compromising the patient's privacy. The Health Record Problem Oriented model achieves all of these objectives. This model comprises: 1. Initial data: the relevant medical histories and biography is recorded. 2. Problems list: the patient provides reasons why she is seeking medical attention. 3. Performance plans: these include diagnostic, therapeutic, pharmacological, dietetic, physiotherapist, and surgical plans, as well as the education of the patient. 4. Evolution notes: the progress of the condition. This model guarantees multi-professional registration, an integral focus on the health, and a continued focus on the patient. These characteristics make it the model par excellence of Primary Care. Prior to the implementation of this model, existing information must be analyzed so that it can eventually be converted to a relational databas...Continue Reading

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