"How to do X in a Problem Oriented Record" If one poses this question one has not understood one fundamental aspect of ALL medical records pertaining to a single patient (as opposed to epidemiological records):
_All_ data is _always_ problem oriented. Any record keeping system "must" support attributing "things" to problems. Exactly what constitutes a problem depends on the patient, the provider, the level and type of care, the current focus of attention, the granularity of record keeping, circumstantical happenstance, knowledge of the day, etc. It may go so far as to seem to not be a problem oriented record -- in cases of extreme speciality, say, a geneticist only giving advice on one specific mutation in a given patient. That is, however, only a special case -- a singular problem -- of a problem oriented record. One can choose to ignore this fact but that is choosing to ignore a part of reality. Not necessarily inappropriate for solving a given problem but still fundamentally wrong (as to our current level of understanding of reality, of course). Documents are a special case since they often display properties of a summary of care over a range of problems and thusly need to be linked with several problems in a target record. Lab results are another case to consider: All things considered every single result (rather than the battery that was ordered) needs to be linked to potentially several problems. Batteries may get ordered "on behalf" of a single problem but results rarely apply to only one. Such is the wetware reality of healthcare involving actual human beings. Karsten -- GPG key ID E4071346 @ eu.pool.sks-keyservers.net E167 67FD A291 2BEA 73BD 4537 78B9 A9F9 E407 1346
