Clinician Attitudes Toward and Use of Electronic Problem Lists: A Thematic Analysis

Complete and accurate clinical documentation is a critical component of the care process. Medical records serve as an organizing structure for clinical decision making, a tool for communication to other providers, substantiation for billing, data for research and quality measurement and protection in the event of legal process. In 1968, Lawrence Weed, MD, published “Medical Records that Guide and Teach” which introduced the concept of the problem-oriented medical record (POMR) [1] and the ability to create and maintain a structured, coded problem list in a computer system. This advance radically altered medical record keeping, and also had important implications for how clinicians organized patient care and decision making processes.