The problem oriented clinical record

Abstract

Apart from its legal, institutional, investigational and pedagogical
dimensions, the Clinical Record is an operational tool and a decisive component in medical care, contributing to and reflecting
quality. In an attempt to approach basic science paradigms,
doctors have been trying to find a rational and organized way
of executing their records. In 1968, Lawrence Weed proposed
a record system that became known as Problem Oriented Clinical Record. This system was particularly directed to general
specialties, which in the Hospital means Internal Medicine. At
the Santo António General Hospital, this is the adapted record
system used in Internal Medicine wards. In the present article,
the authors revisit the system that was proposed by Weed and
present it from a personal perspective, in light of their experience in the institution.