Schweitzer Fachinformationen
Wenn es um professionelles Wissen geht, ist Schweitzer Fachinformationen wegweisend. Kunden aus Recht und Beratung sowie Unternehmen, öffentliche Verwaltungen und Bibliotheken erhalten komplette Lösungen zum Beschaffen, Verwalten und Nutzen von digitalen und gedruckten Medien.
Problem Oriented Medical Record (POMR) has been a standard of physicians' record since it was introduced in 1968 by Dr. Lawrence Weed. However, many physicians are unaware of its principles and do not apply it in a correct way in clinical practice. This book will describe how to systematically write medical records for the diagnostic and therapeutic approaches. This book will cover principles and practice of POMR for care of inpatients and outpatients. The importance of medical records cannot be overemphasized, but many trainees are not educated for the right way of POMR. Thus, this book will provided the right concept of POMR and correct way of medical writing, compatible with the principles of POMR.
Gheun-Ho Kim MD, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
1. What is the medical record?.- 2. Problem versus Impression.- 3. POMR for inpatients.- 4. Admission note.- 5. Progress note.- 6. Discharge summary.- 7. POMR for outpatients.- 8. POMR in the era of electronic health record.
