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Problem Oriented Medical Record

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Problem Oriented Medical Record Scope Medical ... – PowerPoint PPT presentation

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Title: Problem Oriented Medical Record


1
Problem Oriented Medical Record
2
Scope
????????????????????
??????????????????
3
Medical Record
Clinical Reasoning
reflection of
data gathering Hx, PE
data base
4
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
  • ????????????? 3 ???, ?????????????? 1 ???

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
  1. NSS infusion ? monitor BP, urine output
  2. UA, urine gram stain, C/S, H/C
  3. Cefazolin IV, adjust ATB after culture result
  4. Plain KUB / US, FBS, Cr

7
Problem Oriented Medical Record
S O A P
Problem acute fever
Subjective data
  • ?????????????? 2 ??? ???????? ???????????????
  • ????????????????
  • 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
  1. CBC, blood smear for malaria
  2. cold agglutination, Weil Felix test, viral study
  3. H/C
  4. doxycyclin IV

Plan of Mx
8
Ethics consideration
patient right
third party reference
self respect
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