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Problem-Oriented Medical Record in Electronic Healthcare System: Guide to Systematic Writing

Autor Gheun-Ho Kim
en Limba Engleză Hardback – 4 oct 2024
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.
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Specificații

ISBN-13: 9789819741885
ISBN-10: 9819741882
Pagini: 200
Ilustrații: Approx. 200 p. 20 illus., 10 illus. in color.
Dimensiuni: 178 x 254 mm
Ediția:2024
Editura: Springer Nature Singapore
Colecția Springer
Locul publicării:Singapore, Singapore

Cuprins

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.

Notă biografică

Gheun-Ho Kim MD, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea

Textul de pe ultima copertă

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.

Caracteristici

The most comprehensive up-to-date text on medical records available Describe how to systematically write medical records for the diagnostic and therapeutic approaches Explains principles and practice of POMR for care of inpatients and outpatients