Viewpoint: patient-centered medical care requires a patient-centered medical record.
If patient-centered medicine is to become a widespread reality in academic medical centers, educational initiatives must include reform of the medical record. The medical record is part of the hidden, or informal, curriculum of medical school and residency that defines for students and residents the essential ingredients of competent medical care. Whatever its merits, the conventional, problem-oriented medical record (POMR) is a pathology-oriented record that helps perpetuate a disease-focused, biomedical model of practice Patient-centered medicine requires a patient-centered medical record (PCMR), one that addresses the person and perspective of the patient as competently as it addresses the patient's disease. The author proposes a PCMR that includes a concise, upfront Patient Profile; speaks of "chief concerns," not "chief complaints"; makes Patient Perspective a captioned component of the History of Present Illness; replaces the POMR's formula SOAP (Subjective, Objective, Assessment, Plan) with HOAP (History, Observations, Assessment, Plan); includes important patient perspectives on the Problem List; and calls for additional, written attention to the person and perspective of the patient throughout the course of medical care Patient-centered records can guide and teach clinicians at every level of training and experience to practice patient-centered medicine. Moreover, such records can also provide measurable evidence that this teaching has been successful.
Donnelly
William J
WJ
Department of Medicine, Loyola University, Stritch School of Medicine, Maywood, IL, USA. wdon708@aol.com
D004501:Education, Medical; D006801:Humans; D008487:Medical History Taking; D008499:Medical Records / Q000592:standards*; D008501:Medical Records, Problem-Oriented / Q000592:standards; D018802:Patient-Centered Care