The Problem Oriented
Medical Record
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
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Aim-Objectives
• Objectives:
– be able to define source oriented medical record
– be able to define problem oriented medical record
– be able to list items to be included in the medical record
– be able to discuss reasons for keeping medical records
– be able to explain the PSOAP acronym for keeping
records
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It is always easier to find your way if you have a road map!
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Which data are we recording in
practice?
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Why to keep records?
• Helps in medical decisions
(is the size of a lymph node or nodule
increasing with time?)
• Helps to share responsibility with the
patient
• Legal obligation.
• Protects the patient as well as doctor in
front of the court
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Why to keep records?
• Has economic benefits
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Useful to produce health statistics
Provides epidemiological data
Assists practice management
Useful in QI activities
Is a communication tool
Useful in medical education
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Types
According to the method;
– Source oriented
– Problem oriented
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
Source oriented medical record
Data taken from the source are recorded as they are
(Source: patient, relative, laboratory etc.)

Easy and fast to record

Flexible

Omitting information is highly possible

Difficult to access the information
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
Problem oriented medical record
Structure is defined in advance.
 The patient with problem is in the focus
 It is systematic
 Data is easily accessible
 Starts with a problem list
 Progress notes are according to the PSOAP acronym
 Patients problem is in the front line
 Not flexible. Recording information is difficult and
time consuming

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Which data to record?
Personal info
age, sex, occupation, training, family...
Risk factors
tobacco, alcohol, life styles...
Allergies and
drug reactions
Problem list
Disease history
The disease
process
Management plan
diseases, operations
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Progress notes
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main problem, history, exam, lab.
advice, education, medication
in the P S O A P format
PSOAP
Problem
Subjective
Objective
Everything the patient reports and
doctor’s findings which are regarded as
problems
History of the problem; what the
patient feels or thinks about the
problem
Doctors findings related with the problem
Assessment Evaluation of the problem; the diff.
diagnosis
Plan
Prescription, consultation, advice,
control visit.
Source Oriented Medical Record
Visits :
Patient -Source-Oriented Medical Record
21 February 2006: dyspnea, coughing and fever. Dark defecation.
PE: BP 150/90, pulse 95/min, Fever: 39.3 oC.
Ronchi +, no abdominal tenderness.
Medications: 64 mg Aspirin/day.
Possible acute bronchitis and cardiac decompensation.
Possible bleeding due to Aspirin.
Rx: Amoxicilline 500 mg 2x1, Aspirin 32 mg/day.
4 March 2006: no cough, slight dyspnea, defecation normal.
PE: light rhonchi, BP 160/95, pulse 82/min.
Rx: Aspirin 32 mg/day.
Lab :
21 February 2006: ESR 25 mm, Hb 7.8, Fecal occult blood +.
4 March 2006: Hb 8.2, Fecal occult blood :-.
X-ray
21 February 2006: Chest x-ray: no atelectasis, light cardiac decompensation
findings
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Problem Oriented Medical Record
Problem 1: Coughing
21 February 2006
S: dyspnea, coughing, fever.
O: pulse 95/min, Fever: 39.3 oC.
Rhonchi+. ESR 25 mm.
Chest x-ray: no atelectasis, light
cardiac decompensation
findings.
A: Acute bronchitis.
P: Amoxicilline 500 mg 2x1.
4 March 2006
S: no coughing, slight dyspnea.
O: pulse 82/min. Slight rhonchi.
A: minimal bronchitis
findings.
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Problem 2: Dyspnea
21 February 2006
S: Dyspnea.
O: Rhonchi+, BP 150/90 mmHg.
Chest x-ray: no atelectasis, slight
cardiac decompensation
findings.
A: Slight decompensation
findings.
4 March 2006
S: slight dyspnea.
O: BP: 160/95, pulse 82/min.
A: No decompensation.
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Problem 3: Dark colored defecation
21 February 2006
S: Dark feces. Using Aspirin 64 mg/day.
O: No abdominal tenderness, rectal exam revealed no blood, Hb 7.8
mg/dl. Fecal occult blood +
A: Possible intestinal bleeding due to Aspirin.
P: Decrease Aspirin dose to 32 mg/day.
4 March 2006
S: Defecation normal.
O: Fecal occult blood A: No intestinal bleeding symptoms.
P: Continue Aspirin dosage 32 mg/day
Rules in keeping medical records (NCQA)
1.
Patient’s name or ID number.
2.
Personal biographical data
3.
Author’s identification
4.
All entries are dated.
5.
The record is legible to someone other than the writer.
6.
*Problem list.
7.
*Medication allergies and adverse reactions
http://www.ncqa.org/LinkClick.aspx?fileticket=dmQOrIgyvMQ%3D&tabid=125&mid=766&forcedownload=true
National Committee for Quality Assurance
(NCQA)
8. * Past medical history
9. For patients 12 years and older, there is appropriate notation
concerning the use of cigarettes, alcohol and substances
10. The history and physical examination
11. Laboratory and other studies are ordered, as appropriate.
12. * Working diagnoses are consistent with findings.
13. * Treatment plans are consistent with diagnoses.
14. Encounter forms or notes have a notation, regarding follow-up care,
calls or visits, when indicated.
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NCQA
15.Unresolved problems from previous office
16.There is review for under - or over utilization of consultants.
17.Note from the consultant in the record.
18.Consultation, laboratory and imaging reports filed in the chart are
initialed by the practitioner who ordered them, to signify review.
19.* There is no evidence that the patient is placed at inappropriate risk
by a diagnostic or therapeutic procedure.
20.Immunization record
21.Preventive screening and services
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Legal Problems
• Not recorded = Not done !
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In order to prevent legal
problems:
• Record everything you do (including phone
consultations)
• Apply guidelines (e.g.: NCQA)
• Don't use erasable pencils
• Don’t use humiliating expressions
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
Do not use vague expressions such as “the patient
feels well”

If you need to make changes just strike through and
record also the date of change

If you stated that the patient is not cooperative give
the reason

If patient rejects a procedure or test, mention it and
give the reason why you requested it
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Follow-up Charts
• It is practical to use follow-up charts for
chronic diseases
– DM,
– Hypertension
– Obesity
–…
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Charts - Obesity
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Medical Records are Our Road Maps
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Summary
• What are the benefits of keeping records?
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•
Can you explain the meanings of PSOAP
in the medical record?
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• What are the core elements requested by
NCQA in the medical record?
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www.themegallery.com
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