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Problem-oriented record: effect on problem identification in the hospital.

C Z Margolis, N Barak, P Vardy

Israel Journal of Medical Sciences

|November 1, 1984

Summary

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Implementing the problem-oriented record (POR) in pediatric wards increased data collection quantity and type. However, it did not significantly increase the number of identified patient problems.

Area of Science:

Medical Informatics
Healthcare Quality Improvement
Pediatric Medicine

Background:

The problem-oriented record (POR) is a structured medical documentation system.
Previous claims suggest POR improves patient care quality.
The impact of specific POR components on clinical processes needed evaluation.

Purpose of the Study:

To assess the effect of the standard data base and problem list components of the POR on the process of care.
To measure changes in data collection and problem identification before and after POR implementation.

Main Methods:

A standardized audit technique was used to measure process of care metrics.
Data were collected in pediatric wards of an experimental hospital before and after POR introduction.

Related Experiment Videos

Comparative data were gathered from two control pediatric wards without POR implementation.

Main Results:

Data collection scores (subjective and objective) significantly increased post-POR implementation in the experimental hospital.
Data collection significantly improved compared to control hospitals.
The type of data collected was influenced by the POR forms.
The number of identified patient problems showed a non-significant increase.

Conclusions:

The standard data base and problem list components of the POR effectively enhance the amount and type of data collected in pediatric settings.
These POR components do not significantly increase the number of problems identified per patient.
The study highlights the impact of POR structure on data management in pediatric care.