As implied in the post below, the problem oriented medical record has been hijacked by coders and auditors. In contrast, here’s a report from the field in the Journal of Clinical Outcomes Management about a new concept in medical record keeping for patients with complex chronic problems.
First a disclosure. The author is a local colleague, and I reviewed and commented on an early draft of the manuscript. I’ve also seen this system in use.
Potentially adaptable to both electronic and paper based records, the system expands the traditional problem list into a comprehensive treatment summary. The use of symbols enables the summary to be contained in a single page. The summary itself is meant to be updated with key information in real time, freeing up the traditional progress note to depict clinical concerns in a meaningful narrative form without redundancy. You’ll need to get the full text article (which I can’t link here) to really see how it works.
While this tool will facilitate clinically meaningful charting it may not make the coders happy, which is why the author concludes the abstract with: “Feedback and guidance from Medicare audit will be crucial prior to widespread application of the system.”