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

The problem-oriented record (POR) is a medical record format that consists of a standard data base, a problem list, problem-oriented plans and problem-oriented progress notes. It has been claimed repeatedly that the use of a POR improves medical care. The effect of the standard data base and problem list components of the POR on the process of care was determined. Process of care was defined as the quantity and type of data collected and the number of problems identified per patient, which were measured before and after introduction of the POR into the pediatric wards of a regional university hospital, using a standardized audit technique. The same measures were also made in the pediatric wards of two similar hospitals at which the POR had not been introduced. Data collection scores in the experimental hospital for both subjective and objective data increased significantly both after POR implementation and also in comparison with the two other hospitals. The type of data collected was determined by the POR forms. The number of problems identified increased, but not significantly. We conclude that the standardized data base and problem list components of the POR can increase the amount and determine the type of data collected in pediatric wards, while not significantly affecting the number of problems identified.