Abstract

GRANJA, Mónica  and  OUTEIRINHO, Conceição. Problem-oriented medical record in family practice: a necessary update. Rev Port Med Geral Fam [online]. 2018, vol.34, n.1, pp.40-44. ISSN 2182-5173.

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

Keywords : Family practice; Medical records; Problem-oriented medical records.

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