Problem-oriented medical record

The two aspects of documentation are documenting care delivered to patients and documenting progress toward meeting practice plan objectives. The problem-oriented medical record is used by health care professionals to convey information about patient care. The problem-oriented medical record is a means to organize observations into a systematic, problem-solving approach that can be conveyed to others. The problem-oriented approach to documentation is intended to streamline the amount of reading that practitioners must do to update themselves on a patient s status. 

Of the various types of record-keeping, health care facilities frequently use a problem-oriented format. Developed first in medical settings, this type of record-keeping was used to encourage interdisciplinary collaboration and to train medical professionals (Weed, 1969). Working in interdisciplinary health care and mental health settings, social workers find that problem-oriented record-keeping enables them to comply with the facility s documentation requirements. 

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