Problem Oriented Medical Records

Abstract

The problem oriented record keeping system originally introduced by Weed and developed, refined and popularized by Hurst has become a powerful learning, teaching and auditing tool. To the people not exposed to this system of medical data collection, Weed’s original book and books by Walker and Hurst would serve as good introduction. The history and physical examination are documented as is done in the usual routine fashion. At the end of the history-physical is stated the provisional diagnosis and the differential diagnosis as is normally done. This is followed by a clear statement of a plan in three parts. Reviewing the entire system you will become aware that you may have been unconsciously doing this all along. Well, now here is tool which has been de-bugged and put to field testing and available for your use to consciously, reliably and consistently do the same. The learning teaching, research, self and peer audit possibilities of the system are awesome enough to stir up the most reticent amongst us. Try it, you’ll like it!