Problem Oriented Medical Record: Characterizing the Use of the Problem List at Hospital Italiano de Buenos Aires

FRANCO, MARIANO; GIUSSI BORDONI, MARIA VICTORIA; OTERO, CARLOS; LANDONI, MARIANA CLARA; BENITEZ, SONIA; BORBOLLA, DAMIAN; LUNA, DANIEL

Studies in Health Technology and Informatics

IOS Press

Año: 2015 vol. 216

0926-9630

Problem oriented medical record (POMR) was born in late sixties. Expecting an ordered, complete and updated medical record were some of the goals of its founder. Several healthcare institutions have included problem list into their clinical records but some concerns have been reported. These concerns are in reference to their voluminosity, incompleteness and outdatedness. This study attempts to understand how healthcare professionals are using the problem list at Hospital Italiano de Buenos Aires (HIBA). We believe it is essential to understand the local reality applied to our own applications and cultural instances of documentation. This report is the basis from which several improvements could be made in order to meet the goals of Weed´s proposal.