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P roblem O riented M edical R ecord

P roblem O riented M edical R ecord. Scope. รูปแบบการเขียนรายงาน. ประเด็นทางจริยธรรม. new information. problem list. assessment. analysis diagnosis. summary. progress note. assessment. plan of management. treatment / workup plan. Medical Record. Clinical Reasoning.

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P roblem O riented M edical R ecord

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  1. Problem Oriented Medical Record

  2. Scope รูปแบบการเขียนรายงาน ประเด็นทางจริยธรรม

  3. new information problem list assessment analysis diagnosis summary progress note assessment plan of management treatment / workup plan Medical Record Clinical Reasoning reflection of data gathering Hx, PE data base

  4. enhance thinking process legal document communication (medical personals) research study Use of Medical Record

  5. Good Medical Record component aim valid data base legal document complete reasoning, coverage problem list thinking process initial plan communication precise progress note research study communicable understandable summary hospital course

  6. Problem Oriented Medical Record S O A P Problem: UTI Subjective data • ปัสสาวะแสบขัด3วัน, ไข้สูงหนาวสั่น 1วัน Objective data • T= 39.5,BP 90/50, PR 100, tender Lt. CVA Assessment • fever with chill →infection, • dysurea, tender CVA → source = kidney • cause = most likely GNR • hypotension, rapid PR → impending shock? • underlying ? R/O renal stone, DM, CKD Plan of Mx • NSS infusion → monitor : BP, urine output • UA, urine gram stain, C/S, H/C • Cefazolin IV, adjust ATB after culture result • Plain KUB / US, FBS, Cr

  7. Problem Oriented Medical Record S O A P Problem: acute fever Subjective data • ไข้สูงหนาวสั่น 2วันปวดศีรษะ ปวดเมื่อยตามตัว • ไม่มีโรคประจำตัว • T= 39.5,BP 110/70, PR 100,looked ill, no anemic • stiff neck – ve, no abnormal neurological sign • paranasal sinuses – not tender • H & L - normal • Abdomen & CVA – normal Objective data Assessment • acute febrile illness without source of infection, normal host • → sys. inf.- virus, ricketsia, malaria, mycoplasma • CBC, blood smear for malaria • cold agglutination, Weil Felix test, viral study • H/C • doxycyclin IV Plan of Mx

  8. Ethics consideration patient right third party reference self respect

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