Problem-oriented medical record in family practice: a necessary update
DOI:
https://doi.org/10.32385/rpmgf.v34i1.12362Keywords:
Family practice, Medical records, Problem-oriented medical records.Abstract
Medical records are a key component of health care delivery. In family practice, the preferred approach to structure medical records is based on the method proposed by Lawrence Weed’, the ‘Problem-oriented medical record’. It is generally accepted that the ‘Problem-oriented medical record’ comprises three components: baseline data, progressive clinical notes and list of problems. Nevertheless, there is a lack of standards on how to use these sections and, in Portugal, the bibliography on the use of ‘Problem-oriented medical record’ needs updating. This document aims to synthesise and compile the information available, revisiting Weed’s method for practising family physicians and supporting pre- and postgraduate training.Downloads
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