Problem oriented medical record: a predetermined problem list for spinal cord injury.
The Problem Oriented Medical Record is ideally suited to the documentation and management of patients with spinal cord injury, with their involvement of multiple organ systems and need for long term follow-up. The classic format described by Weed has been modified by use of a predetermined problem list, subdividing spinal cord injury into eight problems. We find this method to be of value in organizing the records and managing patients, from the acute phase to the follow-up phase, and additionally in organizing the records of long term patients when seen in follow-up. The problems listed are: 1--neurologic injury; 2--spinal skeletal injury; 3--other injuries; 4--general medical conditions; 5--urologic; 6--gastrointestinal; 7--sexual function; 8--rehabilitation. As complications or other problems arise, they are added to this list. Presented are two case histories, one of a long term patient and the other of a patient with new acute spinal cord injury to illustrate the application of this method.
D000328:Adult; D006801:Humans; D007256:Information Systems; D008134:Long-Term Care; D008297:Male; D008499:Medical Records; D008501:Medical Records, Problem-Oriented; D008875:Middle Aged; D013119:Spinal Cord Injuries / Q000145:classification