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[Problem oriented pediatric record (author's transl)].

R Peris, J Colomer, M L Terrada

    Anales Espanoles De Pediatria
    |November 1, 1977
    PubMed
    Summary
    This summary is machine-generated.

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    This paper introduces the problem-oriented medical record system used at the University of Valencia's Pediatrics Department. It details the format and completion rules for key documents like the problem list and discharge summary.

    Area of Science:

    • Pediatric Medicine
    • Medical Informatics

    Context:

    • The current medical record system at the University of Valencia's Pediatrics Department.
    • Need for a structured approach to patient data management.

    Purpose:

    • To present the problem-oriented medical record (POMR) system.
    • Describe the format and completion rules for POMR documents.
    • Illustrate the interrelationships between POMR components.

    Summary:

    • Details the problem list, discharge summary, anamnesis and physical examination summary, and medical record summary.
    • Explains the characteristics of each document's format.
    • Outlines the rules governing the completion of these medical records.

    Impact:

    Related Experiment Videos

    • Facilitates a standardized and organized approach to pediatric patient records.
    • Enhances data accessibility and understanding within the department.
    • Provides a model for other institutions seeking to implement POMR systems.