ABSTRACT
The problem-oriented medical record as developed by Lawrence L. Weed, MD, has come to be more and more widely (although not uniformly) used in medicine.' It is a logical and systematic method to document the findings and conceptions about the diagnosis and treatment of the patient. The problem-oriented record (POR or Problem-Oriented Medical record-POMR) consists of four major components: (1) the establishment of a database, which includes identification, chief complaint, present illness, medical history, social history, family and marital history, and mental status; (2) the collection of all problems into a numbered problem list; (3) the formulation of plans for each problem, including collection of further data, treatment, and education of the patient; and (4) the follow-up of each problem summarized in the numbered progress notes.
