A medical in which the information and conclusions contained in the record arc organized to describe each of the patients problems. The description properly includes subjective, objective and significant negative information, discussion and conclusions, and diagnostic and treatment plans with respect to each problem. The record, which was developed by Lawrence Weed, M.D., has gained increasing acceptance and can be contrasted with the traditional medical record which is differently and less formally organized, usually recording all information from each source (history, physical exam and laboratory) together without regard to the problems which the information describes.
Method of charting in a patient’s medical record, which identifies the problems, usually in order of importance, and plans for intervention.
Method of establishing and maintaining the patient’s medical record so that problems are clearly listed, usually in order of importance, and a rational plan for dealing with them is stated. These data are kept at the front of the chart and are evaluated as frequently as indicated with respect to recording changes in the patient’s status as well as progress made in solving the problems. Use of this system may bring a degree of comprehensiveness to total patient care that might not be possible with conventional medical records.