Approach to Clinical Problems
From Medical-Wiki
Contents |
Background Information
One of the most significant transformations in the medical record was started by Lawrence Weed, who introduced the Problem Oriented Record. Dr. Weed's premise was that a medical record should not be a haphazard collection of unrelated thoughts.
His work engendered the format for the now familiar SOAP progress notes SOAP note: Subjective, Objective, Assessment, Plan.
Two family practitioners from Vermont, Harold Cross and John Bjorn, followed in his footsteps and proposed what they called a Problem Oriented Practice. They emphasized the crucial nature of a Problem List centered around a patient's problems.
One of their primary dictums was that a doctor NEVER define a problem to a degree of assurity beyond the ability to support that definition. In other words, abdominal pain is simply abdominal pain--accompanied by diagnostic possibilities in the form of a differential diagnosis--until it has been defined with assurity.
An approach to many common clinical problems is described in this section. Problems are categorized according to typical presentation.
