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Related Experiment Videos

Problem oriented medical record: a predetermined problem list for spinal cord injury.

R W Hussey, A B Rossier

    Archives of Physical Medicine and Rehabilitation
    |July 1, 1977
    PubMed
    Summary

    The Problem Oriented Medical Record, modified for spinal cord injury (SCI), effectively organizes patient data. This structured approach aids in managing SCI patients from acute to long-term follow-up phases.

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    Area of Science:

    • Medical Informatics
    • Rehabilitation Medicine
    • Neurology

    Background:

    • Spinal cord injury (SCI) patients present complex, multi-system challenges requiring long-term management.
    • Traditional medical records may not adequately capture the comprehensive needs of SCI patients.

    Observation:

    • The Problem-Oriented Medical Record (POMR) offers a structured framework for managing SCI.
    • A modified POMR, utilizing a predefined problem list, categorizes SCI into eight key areas.

    Findings:

    • This modified POMR system enhances the organization of medical records for SCI patients.
    • It proves valuable for managing patients throughout acute, follow-up, and long-term care phases.
    • The system accommodates emergent complications and evolving patient issues.

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    Implications:

    • This approach optimizes patient care coordination and documentation for spinal cord injury.
    • It provides a scalable model for managing complex, chronic conditions in healthcare settings.
    • Standardizing SCI record-keeping can improve clinical decision-making and research.