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AUTHOR 0TITLEINSTITUTION
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-REPORT NO'pop pATg .NOTEAVAILABLE ERON
EDRS ERICADES4/FTORS
IDENTIFIERS
ABSTRACT
DOCUMENT RESUME
Hanohettl. Effie S.The t System:Public,Healtii.Service (DUOof Health Nanpostik.Sta-18-6 ,
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199p.tational)TechniCal information Seivi el 5285 Port,Royal ROad,*Springfield; Virginia 221 1
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A Liteiature Review,, Washington, B.C. Bukead
NP -$0.83 HC- $1A.01 Plus Postage.*Bibliographies; *Bodumabtation; *Literature Reviews;Nediodk Services; *Nursingli*Patients (Persons),{*Problem Oriented Medical cords
4
14
This,litirature review and bibliography resulted troia study to design a sethedifor determining the imsadt of-the,Computerized problei-oriented medical ,record iPON1), on the nursing
../-components of patient, care. The.PON2 is a system for the ..
,documentation of patient'care consisting of four related components:a data base, problem list, initial plans for each problem, and'progrw notes, including information assessment and.anf revisions ofthe plan. The bibliography is *signed to assist in detl%rnin'ing the* /-
areas in which-the probier,oriented record can assist, and the areas 'in which further develotsent is reguiied. The literature is reviewedin, r
sing and the PONE; (4) the coiputerized PONE; and (5) nursing andfive categories: (1) the nunaing process; (2) 'the_ 43)
nur'
the co puterized PONE. The bibliography of,680 items is 'divided into!
two sectios: the nursing 'process dnd the problem oriented recordand/or system. Access is provided by content area and an authorindex. (Lathor/KP)
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The Prob mOrientedSystern:
A LiteratureReview
..1
111
U S 0E,AIMAE NT OF NEALTYCEDUCAVN t WELFARENATIONAL INSTITUTE OF
EDUCATION
*.4$ DOCyMENT NAS BEEN 4EpRo,CISME° EXACTLY AS RECElvED.FRONTHE PERSON OR ORGANIZATION ORIGIN.'LYING IT RO,NTS04 VIEW OR OPINIONSSTATED DO NOT NECeSSARN.Y REPRE-SENT OCCICIAL NATIONAL INSTITUTE or
.EDUCATION POSITION ola PQ. CV
Effie $. Hanchett; R.N., Ph.D.Research Coordinator
(
Nursing ServicesMedical Center.Hospital bf VermontBurlington, Vermont
Prepared Under Contract No. 1:401-NU-44126
September 1977
.U.S. Deportment of Health, Education, and WelfarePubhc`Health ServiceHealth Resources AdministrationsBureau of HeLth ManpowerOivision of Nursing -/ Hiattsville, Maryland 2078,2
DHEW Poblicatian No. (HRA) 78-6
HRP-0500401
I
*NV
'Ow
4
FOREWORD
:-
This bibliography was compiled as Part o a i4tudy todesigal method for determining the impact of*he comptiter-ized problem- oriented record' on _the nursing components ofpatient care. The literature review islbased'on the:,,systemapproach, which attempts to coMpare the nursiag'procegs ap-proach and the proble6-solving approad of-the problem-ori-ented medical record system. The bibliography enhancescapattill.typf determining the areas in which the problem,-agritnted record can andthe areasin 'which tither7aeyelopment is required, in order to generate the informstion necessary for providing optimum care for the clients
.of nursing services.
Thin publication is the 'third .volume in the Nurse Plan,ing Information Series. The series,is composed of severalselected monographs and bibliographieg relevant to healthpanning.k Each publication in this series has been developedunder contract with the Division of Nursing, Health ResourcePAdministration, U.S.,Public Health Service; dr as an informa-tion source by the Nursing G.-component of the National HealthPlanning Information Center (INPIC).
Ti29, Nursing Componeht of NHVIC provides health plannerswith a centralized, comprehensive source of information onnurse manpower planning to facilitate an improved health caredelivery system in the United States. The COmponent acquires,screens, synthesizes, disseminates, and makes availablespecialized dotumentary material:on nursing,aa well as meth-odological infOrmation on a wide variety of *Tics relevantto health planning and iesourcesdevelopment4 The first twovolumes in this series Pre: Accountability: .1ts Meaning andIts'Relevance to the Health Care Field -and Nursingment in the Health Planning Process.
.4.,
efiglJessie M. Scott
Assistant Surgeon GeneralDirector
Division of Nursidg
.
k
PREFACE
. This literature revtew is based on the concepts that underliea general systems approach to goal- directed activity. The selem.-
Lion and synthesis of bibliographic references is intended to pro-vide the coheren necessary for identifying the qmilarities anddifferences betye nursingvprocess (including probleMr-solvingapproaches used by urses), d Lawpence Meed=s.problem-orientedmedial record (hes4d on ',prop lem-solvifig techniques) .
The rapid rise in popularity IS./ the problem-oriented cedicalrecord and its increasing use by/nurses has'provided a politicallever for attaining approval foX the entry of 'nurses? ,notes oh theclinical record. lamproblem7orienied record has also 'inspireadramatic advahie by proVidihg ajogical method for 'organizing infor-mation on the subject bt Patient care, The problem-oriented sys-tem facilitates Clarity thinking, feedback for audit and edu-cation, and the structur necessary for applying the benefits ofthe computer to the pat ent,!s record.
. . .
Computerized re rds-can provide valuable assistaace forpatient care throw the ability to link medical data'with a spe-cific patient's sp ifie problems. ComputeriAd records can alsopresent a base fo determining high -risk populations and for link-in information risks and the; efficacy of specific.types_of.carin'given p ulations. The compaterited record.is able tolink paEient n eds, provider intet'ventions, and patient odtcomes,and in this w can proxide a powerful tool for nursing research.
tThe s lari, es betireen problem-Oriented and nursing' prdcess
Approaches:are' icing. The differences between, the_problemoriented ecod, as:it currently: stands, and the traditional ..
4proac used by nursing are. subtle but powerful.- The questiohswhich in with regard to the impact, of the computer on ehe'proe7_ems o providing humanistic 'care remain unresolved and unresolv-able at this-stage of development of the system.
The degree of fit possible between the level of diffetediia-ion of information appropriate to any given individual patiedt's
cake and that p ssible, even with branching logic, on a eomputer-ized System, still a matter of disputer The problem- orientedsystem is c to facilitate the collaboration between ;wising
*add medicine. This 'is an admirable goal, but one which can heAchieved only id those settings where the differentiation of the.types of pirOblems,amenaKe to the strategies of each has beenachieved. . ,
. ,..,
-iv-4.
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Nurses have tradittbnally been dedicated to the person as apatient and'to the patieftt as a person. To the nurse, -tie patient,is a person with understandable desires for continual personagrowth, one who has merits and strong points as well as medicalproblems, and Who is able to provide defined data base information.The patient is also a person who has ever-changing roles as partof-a- ?amily and a community, and mbo.ney resolve dther problemsthrough the Successful recording'and care of medical ones. Manynurses have decided to accept those parts of the problem - orientedrecord/sya,tem which facilitate the care of their clients and toalter those parts which do not. In any case, the :servile remainsthe sane for.b.hetient, but the benefits devolve on all concerndd.
C
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Effie S. Ranchett, R.N. , Ph.D.
-v-J
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ACKNOWLEDGMENTS
'Mk
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This literature review was made possible by a contract from theDivision of Pursing of the 'U.S. Public Health Service. Dr. EugeneL6iae, Chief, and Mb. yirginia Saba, Nurse Consultant, both of theManpower Analysis and Resources Branch, provided the liPicon betweenthe Division of Nursing of the U.S. Public Health Service and MissPatricia Kelly, Director of the Department of Nursing of the Medical-C. ter HOepital of Vermont. Without the generous assistance of the
lic Health Service, this work would not have been possible.- His"Kelly offered both the opportunity aad the retouroee of her departmentto enable the work to be completed.
The personnel of the Given Medical Libra ry of the University ofVeltant are owed a debt of geatitude.for_Sheir generous_ assistance.A continuously updated bibliography on the.problem-orilmted system ismaintained by this libiary, and this resource was shared with me. M.Sars-Nixon, reference librarian, was particularly4helpful in answeringqueitiondrand offering available resources. Ms. Donna Carlson, whodirected thessanyinterliheary loan r ts; Mr. David Dudly of thelibrary; and the printing department IT:Onnel of the Medical CenterHospical-of Vermont, who xeroxed large amounts of material; imit alsobe thanked for their gracious assistance.
1,
Ms'Diane Ely, B.S., R.N., assisEed with the internal organizationof the material and suggested many valuable additions tp the Contents.Daniel Griffin, of Aspen Systems Corporation and the National HealthPlanning Information Center, provided valuable assistance in editingthe material. Mrs. Suzanne Senesac proofread the material with theprecision that results from kaowledge,'care, and dediation. .She wasassisted by Ms'. Bonnie Wilfore and Mrs. Dor4hy Maguire. FinA317,Mrs: Janet Burford typed the first draft of the manuscript, while ks.Janice Dubuquettyfea the-final, camera -ready 'copy. Both typed andedited large amounts of material despite a great deal of time pressure,with consistent patience, competence; and good humor.
4
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coirnarrs
iit
PREFACE E iv
ACINOT,(LEMENT S . .. ".
I.WISTRODUCTION.
II. METHODOLOGY FOR THE. LITERATURE REVIEW% . . 3
7
'7
'III. CONCEPTUAL FiAME9ORK
IV. THE LITERATURE'S 4
41A. NURSING'PROCESS . 4. 76 , ,
Background,- 7
Componepts of the Nursing Process ,. 9
Summary: - , 19 (
B. THE PRoBLEMORIEht.ED MEDICAL RECORD (1101110 19Introduction
, .._ 19Background
22General DescriptionsPof the PAplem-Oriented System .. -24Advantages, Disadvantages and/or ontroversy Overthe
Problem - Oriented Medical Record System .27,Initiatimig the Problem-Oriented ord and/or System 32Applications of the Problem-Oriented Record 33
.9 Studies and Surveys Regarding the Problem-OrientedMedical Record. , . . . = .0. : ..P.
? 43Modifications of the Problem-Oriented Record 48
. Manuals dad Teaching Guides for 'the Use of the Prob-.1em-Oriented Record and' /or System 48
.
C. NURSING AND THE PROBLiMORIENTED/RECORD,
.48,Introduction 48Concepts, Philosophy, and Descriptions of the Use of.the Problem-Oriented Record and/or-System by Nurses . 49titiating the Problem- Oriented Record and/or System. 53
Applications of the Problem-Oriented Record d/orSystem r
56.
t
Studies Recording the-Use of the Problem-Ori tedRecord and/or System
, 62- z
Manuals, Workbooks, and.Forms,., 65 .
,
.1
Nursing Inno'atiens and_ Adaptations of the Problem-
'oriented Record65
eS
-At
. Concl
Nursing ProCess and Problem-Oriented .Approaches
D., TEE COMPUTERIZED PROBLEM-ORIENTED RECORD ...
fdtroductiopBackground. . , .. . ...
Concepts and Philosophy . ... ...Descriptioni of die Computerized Problem- `Oriented
System ,
Initiation.-and Acceptance of the ComputerizedProblem=Oriented System
Applications of the Computerized Yroblem-OrientedRecord. ,
Studies Regarding the Computerized Problem-OriedtedRecord
E. NURSING AND THEIntroductiona-pet-lance With
-Record
COME'UTE.RIZER-PROBLEM-ORIENT* RECORD
theTComputerized Problem- Oriented
F. SUMMARY AND CONCLI1IONS t1
. `LIST OF BIBLIOGRAPHY ITEMS BY CONTENT AREA.0 A 4
BIBLfOGRApHY *.
A. NURSING PROCESS- Books and MonographsArticles
66.
A68
68-6869
76.
79
80
80.
80
81-
82
85
87
101
"*101
101
102
158
B. THE PROBLEM-ORIENTED RECORD (POR) AND/OR SYSTEM (POS) 106Books ti
Articles, -Backs, and ,journalsUnpublished and-Other Materials .. ..
'C. INDEX OF AUTHORS
I
7
. 106
109'
'151
-1000
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THE RROBLEK-CiRIENTED-SYSTEM: A LITERATURE REVIEW
.*
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,
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IA
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I. JIATTRODUCTION
I
This annotated bibliography his been designed to complete d re- ,
quiremthtt of a U.S. Public Health Service,' (N01-NU-44126) to design a method to
Division or Nursing, contractevaluate "the effects of a com-
1.
puterized problem-oriented recoit. on the nursing components of patientcare:".
The material has been organized into ,the following areas:
)1.- Conceptual 4nramework underlying both nursing process and the
..problem-ori nted record.A
2. Nursing-Process.
3. The problem =oriented record:a.) ,Background, philosophy;b.) Initiating the problem-oriented-record; N'c.) Applications of the problem-oriented record settings;
Studies regardingthe effects of the problem-orientedrecord; , c
e:-) Miadifications'ofthe problem-oriented record;f.) Manuals. 6
4. Nursing and the problem-oriented record:a.) Brkground, philosophy;b.) Applications of,the problem-oriented record by nurses;c.) Studies regarding the effecta of the problem-oriented ree-
ord as used by nurses;d.) Manuals;
e,) Modification of the problem - oriented record as used bynurses,;
f.) Nursing process and the problem,orieted record.
5. The computeri2z lk problem-oriented record.
r.
6. Nursing and the computerized problem-oriented record.I
II. METHOWIAGY FOt 1.11k. LITERATURE REVIEW -
The search for.the literature regarding the problem-oriented; rec-ord was conducted betweegOctober 1974 end Deeember 1975. Two majorsources were used.' An initial Medlars/Medline search was conductedduring October 1974. "The Problem-Oriented Record" doesnot constitute,a headingsfor this system; As a result, several headings were used,and the titles obtained scanned. ( "Browse" commands for the exist-ence of "Problem - Oriented, or 'blem Oriented" in their titbits,
O
: 11!
The 'Medlars /Medline -headings used were:
NURSING-RECORDS,NURSINGrAUDITNURSING-CAREPATIENT-CARE :=PLANNIii&
PROFESSIONAL-STANDARDS -REVIEW -ORGANIZATION.
PATIENTSHOSPITAL:NURSING-STAFF.HOSPITAL - NURSING- SERVICE
. 0f the L746 occurrencesygdithin these headings, the nUmber?of,documents in which the title "Problem-Oriented",br\"Problem Oriented"occurred was 23. Two documents'were located from the off-line Search.The reference librarians of the Dana Medical Library. at the Universityof Vein:ant provided a xeroxed copy of the content gsted under "MedicalRecords'Irom the Index MediCusiListings. JoAnn Gustafson of the PROMISLaboratory compiled and maintained an updated list of references on the '-problem-oriented medical record from these copies. This list of refer-,ences provided the bulk of 1he references on the problem-orientei rec-ord and/or system which are includ d in thiihiblioxaphy.
_VA later Medlars/Eadline searah was conducted in March 1977. Thiswasjped to update the listing of articles from January 1976 to thattime. The title "Problem-Oriented" now exists in that system and wasused foi this purpose. .
The Togas'Veterans Administration (Pfifferling 1974)had pre-houslydeveloped ebibliogiaphy on the problem-oriented'record. Additionalreferences were obtained from this source. Other references were ob- , .
tained from secondary sources"(bibliographies of articles) and'frominformal sources, such as word of mouth. Foreign language articles andjournals were omitted from this review.' Compiling a complete list ofthe literature regarqing:nursing process and nursing, process approacheswas not intended. --
qtr.
The fies\d.ing of Problem-Solving Approaches was considered for4811 .
issues of the :Cumulative Index to Nursing Literature listed during thetime period of 1972 through March-April 1975. This produced listingson both nuitsing ptocees and problem-oriented approaches. The materialon both problem-oriented and nurising process approaches was organizedaccording to con-zit area,, and is presented in'the "List of Bibliggraphy
Items by Content Area" which follows the text of this review. (See p.85.) Items relAtedto a ,specific area, but not reviewed in .the text,are identified by content area within that list for those who desiremore information about a specific content area..
9
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-,f. A general systems approach to ioaloriented bellavioi provides a
conc2ptual framework underlying. both nursing.process and the problemoriented record:4 Rosenbleuthand Weiner (1968) .defined puilkoseful
itbehavior as "Behavior orientednowa'rd, or luided,by a goal" ekosea .Tileuth and Weiner, irk Buckley; p. 236) .o
_.:-.. .1..
II CO NCEPTUAL
IP'1
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2-
The basiC elements of)this approach are(
f. Information gatheting;
2. Orgpn47ation of the information gathered into_ an assessment or. ,
.
3. Definition of the goal;.
.
4 c
4. .Establishment of a. Dian to n>et the goal ;
. =1 A
,5. Intervention, caring out .the action designed to move the sysT
tem toward- the goal..
. i .
Ttese. steps constitute an interacting cycle of activities (see fig. 1)..
No one activity occurs alone, in professional nursing, no onepatient factor is .con'si4eted wittiout evaluating tOe influence of other Afactor's and the wellbeing OT the patient as a Whole. .1 k.
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.
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SEQUENCE OF ACTIVITIES IN GOArDIRECTED BEHAVIOR
a I
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IV. THE LITERATURE 4.
- I "4
A. NURING PgocEss,
"Nursing process" is the term. used to "describe those activities ofthe nurse%hich are often also described as,"problem-solving.techre..ques.",It is a dondeptual model ,for diffeientiatiin of the nurse's goal-directed activitieslipdata,gathering, assessing, planning, intervening,and 'evalUation. The activities of the nurse, rather than the needs of /-the client, provide the focus for analysis.
When considered in the context of gerrral systems approaches togoal-directed activities, six discreet colcepts must be considered:
, p
1. Information gathering;
2. 'Assessing the organization of bits of informatiOn into meanings;
3. Goal setting; Ne
4. Planning methods'to achieve the established goals;
5.' Intervening, carrying out he plans made;
6. Emaluating the.pffects of.the interventions in light of theestablished godls.
.
4/ // Background
Adelaide Nutting ,rand Virginia Henderson stated that the cagestales carried out in Annie Goodrich's ,era at Yale were'the beginningsof the nursing process approach. Care planning was included inHenderson's 1939 revision of Harmer's Principles and Practice of Nursing{(Henderson 1973).
.
,;
According to Hawken, Adelaide Nutting admorritheAnurses to "observe,assess and formulate plans for nursing action in .19b6:(Hawken, inWalker and others 1973,1). 289).
Fry's article, publishea in 1953, stated that a creative approach101.!" to nursing4nvolves a nursing diagnosis and the design and means for
tarrying out a plan for the'care of an individUal person '(p. 301). Shethen proceeded to identify five areas of Patient's needs, which serve asthe basis of nursing diagnoses:
1.. Treatment andmedication needs;
. Personal hygiene needs:**
EnvirOnmental needs;,
4; Guidance and teaching needs;
_5; Human, or self needs.
- -Her focus was balanced between attention to patient needs &ad...attentionto nursing activities to meet these needs.
Abaellah listed five basic elements of nursing in 1957. Sever 3.
,of these closely resemble the basi' concepts of the nursing process,approach: 'ability to observe anditeport,signs and symptoms (data gath-ering), ability to interpre_thest (assessmerit), and organization ofeffort's to 'assure the desired outcome's (intervention). In addition,she specificF11y identified the need to'analyze'nursing.prolliemi,cluding the ability to:
I. Plan', for total.cd.xe,
2. 'Selectoa necessary course of actions
3, Help; the patient attain a ?ealieti6 goal.
gkfe.years later, Ur1962, Chambers' description of "nursing diag-nosis"_desdribed these components of the -nursing process in a sequence'which more closely resembles the one currently in use.
1. Collehting facts,
2. Interpreting facts,
3. "Identifying nursing' problems,
4, )eciding the course of action,.
,5.'- Evaluating results.
Kormorita's list.was published the following year (1963). Itclosely resembles that of apambers', except that Kormorita added plan-ning to her list of elemen* of the "nursing diagnosis.". The firstpublished account identified in which the.term "nursingprocess,"rather than "nursing diagnosis," was used for these elements was Yuraarld"Walsh's account published in 1967.
Bonney andRothberg '(1963, 1967) identified the same elements butorganized them into two categories., Nursing diagnosis' includes the
.1_
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4
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identification lof individual lieedereStablishent of tOals1 and SeZ:ec-tion ofrapproprie5te methods% Nursi 'thOrapy,includes nursing careplArning and nUrsing intervention;
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.Little and. Carndvali 0196.7, 19 and iImmerman and 4:(1§70)7_kprovidedsimilar descriptions of t. urs:Ing process." ifuraang*Walsh(1967, 1973) listed simIlarcopon ,s, hart placed more hasis:on-
`environmental ("influencing") 404tors.andveurse-client interactions.FrePmPr. (1970) listed the 4Tevents of he-nursing-prOC'ess'as weellS' I"
/ through which dommunity health nn' ing is conducted: - (....-
.... .
(s:Daubenmirand King 0973) described sing process from thefoal pqint of the-nurse-client intetactiotather than the nurse'sindividual problem-solving techniques.' Most later approaches differlittle from the usual descriptions, of,the.pFsing Process and include,Nicholls (1971.), Roy i1975), and Mund4ng rind Jauroq)(1975).
1
.Components the Nirsini Process
,C
- */ Individual components, of the nursing,process have been 4 cussed. i.by a variety of 'atthors. Even tho'i it,is recognize§ t4at'Zhe nursing
coinponepts of patient care are continuously interacting with.eachother in the "real world" of professional,11g--activity, each willbe consi4ered separately.
Infornat, s Gering, ... . . .., . ,
k...
There a.1. se oral approaches to inforAtion'gatiaering presented inthe 1:,terature. They'represeni, a continuum of unstructure&thrqugh
-:
structured 'as in the data base of the psOblempriented record) ap-proaches. In Hammond and others.' (1966) rticle of the series "Clinical ,
Int'erence in Nursing" in Nursing Research,. the authors discussed the. infcrmation-seeking strate5ies of nurses( SP:mlittitteous and suCcessive 0,,scannigg patterns are iaentified for different nurses. h, .
! .
Ujehly(1968)'argaed that an unstructured approaCh strengihens-thenurse-,c14ent interaction. The' patient is 'allowed the freedom to verbal:-ize,his concernsAccarding to is own prioristiet. This atproas.h relieson the nurse's skill in perception of verbal and nonverbal cues to iden-tify the areas in which the patient avoids rect, verbal communication.It Also relies Owthenurse's communication kill-to elicit t4ii-4or-
,nation necessary to plan care, .
.
Lewis ( 70) stated: "the fivi ility c. the semistructured inter-view is one of its prime'advantages. It c'an be adapted to the patient
16
fry
and the .nurse to allow for free expressions of feelings, attitude , an&
/beliefs in relatiOn to the patient's life experiences." She off red: ti /
"these pritvide more cues than the-mere factd.of hii life" (p. 42). //I
_Whetridge (1968) presented anursing history form with spenifiqquestions but stated that this is:intended to be used,Onlf as a guide. /,The interviewer is-free to rephrase questions and explo different-,areas to different degrees of depth 69).. An additio area is Oftfor "other concerns" ,(part 3, no. 3).. The average time equired forthis process is 25 minutes. This guide is organised in four areas!
1. Patient perfections an expectations related tc illness /,'
hospitalization.
2. Specific patient needs. This section provide an excellentbase for "tailoring" the patient'Sneeds, and considers factorsin perceptual and motor abilities and rhythmsg-& .
/
3. Other. This section inclines allergies, edud'itional'levelachieved, and any concerns wh.b the Tatientimazfhave.
4. :Rnrse's impredsions and suggestions. t.
A defined data base for rehabilitation patients was developed byBonney and Rothberg (1963). Specific information in. areas of mobility
guide -which includes emotional, spiritual; physical, social, And inaand self-care vas identified. Garant (1972) published an assessment
lectual'domponents. This is the least structured of thetstructuredformat apprgleas. /
Assessment
Hammond (1964) stated: "The coTplex tature.af.nursiag inferencesis based on multiple cues of different levels of quality used to judgethe state of the pattent." Re also suggested that different nurses use
-.different inferdhce patterns.
tOIn a later article in the sane series, Hammond (1966) reported t1A-
findings of a study condhdied to identity single cues or mnitiplegroupings which constitute_a message unit for the nurses. Althoughinconclusive, the findings suggest that no single cue held independent.7Tsignificance for any of the six nurses studled...Rather, the d.dta suggest that single cues are organized into cue grauppmgs. which constitutea message unit forhe nurse. Cue groupings were Organized into largercue configurations. The cue configurations were used differently byeach nurse and were likely to provide theAEtsia of her inference.
Durand and Prince (1966) considered nursing diagnosis to be anyaspect of the patient's condition that requires nursing care. They
V.
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t
discussed fact gathering and pattern recognition as central to anydiagnostic process. 'EXamples of nurOng diagnoses are provided. -
These include physical, psychological, and coomunication problems. .
Levis ( 70) included strengths and Weaknestes, concepts of -meaning,-and pattern in her brief discussion,of thq analysis of data obtby information.gathering\-(Ievis 1970, pp. 65-66).
ofand
.(1973) discussed asteasment in terms of knowledge of htm_an needsvis,hthan behavior, and characteristics of a helping relationship/(p.'.19).They also stated that the nurse needs a model of health to servea,hasis for asses rent (p. 82). The nurse t also know the maj rI*47pathologic and psychopathologic insults to person at various de- 7
velopntal stages (p. 83).
Hamdi and Hutelmyer (1976) piesent a review,cof the literatureregarding tools for nursing assessment before deCribing their ownst6dy. McCain's "Guide to th,,Syst%Matic Assessment of the Fizactional
pt the Patient" was modified for diabetics and was pretestedvith 10 patients. In the experimental phase, the 10 patients werestudied. Each was assessed by on rse xho u?ed the experimentalassessment tool and by one nurse o did ,hot use' the aessment tool. .
y
the expeittental group identifiedifewer of the patidiat's nursingcare problems. Ho;iever, tdre.of the prOblms 3APntifibd through theuse of this tool here Judged to be validly based on supporting data.The authors dfcl not indicate.-whether or not their assessors were madeaware of the study's criteriy of the need tor written evidence ofsupporting data. There,-/as do di9cussion of the significance of theless "valid" problems yhichkyereident4.fied through the unstructured
). control method.ti
Sett
Av.' Goals or objeCAes for patient care arise true the goals -----ama
values of Ehe nurse in combination with ose of the patient.:Mw_ -greater the Congruence of goals of both es,-the greater the'energiei which are available for the pursuit of these goals. Freeman(1974 ,pp. 62-63) discussed the'need for the public health nurse tobrig her own goals, the goals of the.recipient/bf her ter Vices, andthe goals of the broader community into perspective. She differea-,.tinted between truly maitlia.*gcal setting and seieing.the complianceof others.
_MauksCh and David (197) included goals within their model. ofthe nursing Ptess and used goals Aithir than problems as a reference -
/point for both lartniag and intertention. They stated that goals must/
be measurable, attainable, reasonable, and representative of thepatient's aspirations. The reasons and' methods for establishing goals
_)sere giyen by Mager (1962) in Otis programmed instruction text. Besented.the reasons for educationsl objectives, Oeirvaslities
;
(the comuniCation of the teacher's intent), and the methods forrecognizing. their achiev-ent (through the initial careful stat-entof the bjCtive). He also provided-instructions for preparing and
*R.
;-stating..measurable objectives.
§:ith 1973) qsed'Mager (1962) as her frsmevork. She arguedstrongly r the use of behavioral objectives in nursing, and stated:"We rust egin to measure in a systematic vay what ve acco=plish forand with patients and ve must put this into words that can be under-stood" (p., 320). She provides examples of specific behavioral objec- .
tines and also presents objections' to this approach- S=ith alsostated that are develked from fatZ-obteined from thepatient as well as from nursing knowledge: She considered objectivesto be a series of compromises betvien ideal and real. The ideal 'isobtained fro= nsing's r.odels of health, the real fro the constraintsprovided by patient and enviruu-ental resources.
tE:Yura and galsh (2973) differentiated between imMediate, Inter-
=ediatb, and lbng-range goals in their section on priority setting(p. 96). They describe as1cw's hierarchy of need and Erikson'seight stages of development as fi-a=esiorks forneeds. Zimmer-=an and
Gohrke (1970) presented the concept of "negatie goals" or the' lackof deterioration as a goal in 5o6.4 situations.' One exe=ple is thetreventiot of skin breakdown...,
.
1
Levis -0970) considered goals within the cons axt of objectivet.She stated: "cursing objeotives describe the int/ ded OUtcr_e ofthe nursii4 action" (p. 644 She also diffe ated between short-tellm and long-ter= goals, and between objectives for the patient (theepatient viii b able to tpke ,pare of his own colostany) and objectivesfor chat the nese do fdr the patient (teach coltystomy care). herapproach to the latter, cased an Mager's concepts, considers specificpatient outc=es to be =ore measurable and therefore to provide betterevidence of the success of nursing intervention.
Lewis also discussed "conditional outco=es"--those conditionsA
which are required for a specific oUtco9e to be actieved. She pointedout that although certain genex!al Objectives-for specific cOmmonpatient proble=s ay be ide tified, nursing:tbjettives and evaluationcriteria rust be personali to the patient (4o, 89).
Little and Carnevali (1969) included consideration of goalsthroughout the content of their work oh nursing care planning. Theyconsidered the state=est of goals or objectives for nursing action tobe an important clarifying element in care plans and stated that they"serve to crystallize tfiedirectians, the distance the nurse hopes tohelp the patient travel, the probable approaches and the measurettntof patient responses" (p. 173). They differt.Oriiated betveei short-.
term and long-term goals anediscussedseveral factors in Changing
19-
(
9
t ":
goals: the imdgre.si ot tht patieryt, the discovery of 45qr.adictionsbetween nurse and client goals, and 'the constraints of the realitysituation. o
A.
if Little and Carnevali (1969) also spoke Ofthe balance betweendegrees of specifi5ity orgoals-,"thOse which are too specific as torecuire clgnStant revii&on, and those which are so vague as to rarelyrequire Cnange"..(p. 165) . IA discuSsing the teaching of care Iltleming,they stated that teat ing the use of stated goals should enable thelearner to:
1. Became aware of tne'value of goals in day-to-day nursing
2. Perceive the clifferences bet': patients' goals and thoseof the nurse, and the influence that this can have on theirinteraction.;
CL.N.0/
r
Se: achievaba"i 1,c,e-ls that fostlkorderly, logical progressionof nursing care measures fp. 228).
Patient goals or 6bjectives'are included in Wagner's (1969) de-scription of the Issentialcomponents of a nursing care plan. Shestarted~: "Am objectie should get don tO basfc physiologic orpsycholOgic behavior" in ordet to provide something to aim- at (p. 988).Another charateristic of the care plan which she ide tifies is("currency." Shk_stated that care plans must be flexi d that.Ce=11:31:, or course, be able to modify` our goals and appro creek if they .
do not work, if conditions change,or if continuing study f the patientre -suits in a clearer picture of his problems" (p. 989). Sie alsostated that objectives must be-achievable.
JThe nursing care plan consists- of a conscious statement- of
sequence or pattern of activities Lich will be used to achieve thestated goals. The bactground of nursing care ',Dann is disoutsid byCIA:ma and also bv.Henderson.
Ciuca (1972) presented-a review of the literature regardingnursing care plans .up to the ileEe oiler study. This constituted the.'introduction to her study of the'cont4nt of nursing care plans. There- .fore, her- primary object +e in this review was to identify the elementsincluded within previvus authors' approaches to the care plan.'Tiendprson's (1973) letter to the editor, printed as an article, iden-
tified the forerunners of nursing care plans: the 'study" intgasen's Student Handbook on cursing Case Studd (1929)i A CurriculumGuide for-Schools of.riursing41917); and her reviIThi of Harmer's.Th9rPrincinles and Practice of Nursing, (1939).
4
r
2 0-13-.
aia
41%
Definitions of pUnning vary fram author 'to author. Many areimbedded in 'concepts of the components of nursing care. Roth-berg (1967) agfined "nursing care plans" as a step toward nursing° .therapy. She stated that here is absolutbly no pointnursing diagnosis unlees'it leads directly to action in th farm ofnursing therapy. Wagne 69) defined a nursing care plan as '!a,written-picture of tlie patient and his nursing care which enables,thestaff to give him the kind of care he has a righf.to receive"(Browhing and Minehan 1974, p. 239).
.
Yura'and Walsh (19T3) stated: "Planning means to detern4ne-what can be done to assist the client. The essence of planning in-cludes a deliberate approach to set4ing precise goals, continnOlyvalidating.the data, establishing priorities, and mAking decisionsabout speciffc measures to resolve his problems" (p. 29). Kramer(1972) stated that there should be only4.tvo main purposes for thenursing care plan--to foster continuity and comprehensiveness ofpatient care (p. 30).. Lewis (1970) stated: "The plan is-a resultof the combined efforts of nurses, patients,. family, and other mem-bers of the health team to find ways in whihi.nnrses can assist thepatience with fits needs."-
Browning and Minehan (a974) presented a collection of a-
rticlesfram tiie Ame Journal of Nursing Company's publications re-garding th anning of nursing care in section V of their book. Thebrief int action to this section states that nursing care planshave been evolving for at least 40 years and as such are the oldestcomponent of the nursing process. The statement was also made thatpreoccupation with care planning has overshadowed the other elementsof the nursing process. Articles concerning benefits,. problems, andobjections to tire_ care plan are also inluded.
Leafs (1970) considered several.nursing components of patientcare under the title "PlAnnIng."` Her approach is sensitive, both tothe uniqueness of each patAant and to the complexities of the nursing {1jda.ceis,._ She stated that each step of the nursing process (aspt.;-ment,.intervention, and evaluation) influences and is influencethe others (p.79). She discussed decisions regarding the timing /anA sequences Of care, the need'for modifications of the plan with t
changing patient c tions, and the formulation of;objectives underher consideration f planning. Her definition of approaches is "the ,nursing activities lusterid around a nursing objective" (p. 91). A
Her 4iscussion.of,the selection of-alternatives (pp. 91-94) includes 'le
consideration. of the consequence, probAbility, and desirability ofapproaches.
Yura and Walsh (197)) consider planning,throughOut the contentof their book.
*The discreet section on planning (pp.-28-29) ad-
dressed this activity within the context of goals and actions. They
. 4
-141-
2 1.
1,7
stated: "The essence of planni includes a deliberate approach tosetting jrecise goal, both ult to and proximate, continnailyvalidating the data obtained by assessing the clientts Ablems, es-tablishingTrioritieS and /making decisions about specific measuresto be used to resolve his problems" (p. 29)., &later discussion ofplanning (pp. 93-107) includes:priority setting, nursing orders,and thenursing care plan. Yura and Walsh .(1973) considered the .
clearly stated nursing careklan to be the most effective means ofassuring the client that hi problems will be saved and that his 4basic human'needs will be fulfilled. 4,
Mayers (1972) condide d th.e problem-soliing approach as basicto nursing care planniag. e ificluded several chapters in her`discussion: ch. 3.,""The oblem as the Basis for Care Planning;"ch. 4., "rne Expected Outcome as a.Standard for Evaluatiqn;" ch. 5.,"The NurSing Action as the Strategy for Solving Problems;" cll. 6.,"The patient's response as a test of Good Planning." Usual and wk.usual problems provide a recurrent theme in her consideration ofpatient needs, and a chapter is devoted to standard careroutines.She argued-that the pendulum is swinging may from the foe& onindividwoized care plans and returning to toe mitidie of the road.It is ltational and valid to consider Vali similarities and differ-
.-ences between clients, she stated.,
4(--"\Assets and liabilities of the nursing -care plakwere presented
by Kramer (1972). She stated her concern that care planning w1141 ji7become an end, rather than a means, for Fatient care. She felt tlitytThis could be resolved by trimming the numerous purposes Of the careplan to two:basic and functional concerns:' (1)-the coordination ofcare and (2) the continuity of care.
Ciuca's (1972) analysis of 235 nursing care plans from 6 hospi-tals in the San Francisco Bay area snows the content of the nursingcare plan to be primarily related to the ppootation of qAnRtionalduties °Dedications, trea.r-uts, vital s gns, I & 0, and diagno is-studies). "Notations indic ing the planning of n4rsing care actionwere conspicuouslyabsent" (. 231)0 Possible reagond for this 'omission include lack of admii.strative Support, lack of staff skillsin this area, land/or a low priority on nursing care planning. Itmay be that the nursing care planis not seen as a tool for-nursingpractice. Adequate consultation and an adequate roll model might .
help to remove this barrier.
N.,
Nursing Intervention
. Definitions of nursing ifitervention have been given by .manyauthois. Yura and Walsh (1973) stated "IMplementation involviiktion; it is the phase in which the initiates and completes
22
. I
the actions necessary to accomplish defined foaler(p. 20).. Levie(1970) stated: -"Nursing actioni'test theghypotheses posed in the
,planning st4e"." She also enumerated specific types of nursingaction in the Chapter of her book, "InterventionNursing Action" ,
(pp. 109-117). Freeman (1970) described mobilizing available re-'sour spe for care one.of the elements of the community nursing ,
process (p. 65). Mayers (1972) defines sr nursing action as a"specifically recommended, individrlized.nursing activity designedto solve the patient's problem by f proAtedpoint in time." Shestated that several nursing -Salons may be necessary for the solu-tion of one problem (p.
Attempts to list or 'to-identify hureing activities often becomebogged down within the complex levels of nursing intervention.Abdeilah's-"21 Nuraing.Prqlems" (1960) provides one approach. Gebbieiand Lavin's (19744 eat Royis"(1975),-atiempts to establish's Consistentnomenclature far nursing diagnosis constitute another-approach. Lit-erature regarding nursing Intervention itself would necessarily in-qtelude review of all the basic texts on nursing care and is not rele-vant to.the.purposes of, this review..
.Evaluation
--
The evaluation component Of nursing care is a combination-ofboth the information-gathering an<( the information- organizing compo-nets. This is done both concurrently with and after the completionbf the other cdrnpone*s of nursing cam.
Yura and Walsh (197!) considered evaluation as one of the nursingComponents of patient care and stated: "evaluation means to appraisethe client's behavioral changes due to the actions of the nurse"(p. 30). They considered it to be the fourth component of the nursingprocess which follows the implementation of actions designated inrthenursing-care plan {p. 120). They included nurse; client, and familyas agents of evaluation.
Lewis (1970) considered evaluation tol'be the.fihal step in thenursing process. She differentiated between the evaluation of patient,care and the evaluation of the nursing care plan (pp. 118-122). How-ever' she considered ongoing Uprialsal within her capper on datacollection and suggested the selection of relevant indicators of change,(pp. 51-53). 'In her earlier article (1968), Lewis stated, that evaluationdetermines to what extent the careAgiven is successful in meeting thepatients needs tp. "n). Zimmer (WT4)' Stated that assessment of out-comes of care is a powerful means for quality assurance-(p. 317).
Daubenmire and King (1973), referring t their interpersonal'tmodel, stated that the nursing process is manic, ongoing, inter-
, ,
4--;6
a.
a
. .
.
.
'personal process dependent on. the changirig. behavior of patient andnurse, and that the nurse must be continuously observing and measuringthe changing behavior of b nurse and patient (4, 516).
4 Hammond (Fall 1964), his witty but meaningful description ofthe wood tick's behavior, 'fferentiated-between the wood tick, which
. responds in a.singlefashion t o g single cue, and the nurse, who__-responds in a complex fashicnto complex cues..
There are two systems for evaluation: the patient's'signal-,
Sending system and the nurse's signal-receiving .system (p..31T).
Central' Questions forevaluation of the state of.the patient are':e.
1. -Has the patient moved closer to achieving the nextdevelopmental goal?
/ . .
/---1-k. What are the costs of this movement.(pain, discomfort,
.
instability, and/or loss of previous developmental aecomnt i-plishment)?
3. What quantity, quality, and Iti'ma patterns for the pro-iisi,pn of necessary resources have been most effective andleast costly to the client and his significant
7
'Nicholls '(l974)-;presented the following model (p. 216) describingthe process in which changing patient needs result inchanging cuesand actionI t9 maintain a system of care which is-congruent withpatient needs.- When a nursing care plan changes in response to a,patient's needs, the standards, feedback system, and actions tomaintain performance also change.
. 24
c
1.%
.1
6
FIGURE 2
NICHOLLS' MOBOL.FOR, MAINTENANCE OF CONGRUENCE OF NURSING CARE.
IN RELATIONSHIP TO PATIEpTS' NEEDS
Identify' faces and assumptions
underlying patient problemsand select nursing strategy
ABEISS patient andresources
Information
Feedback Int- retation Action
nursing actions:' means standard
acts related to`sing perform\
ance
a
continueperation
. facts do not 1. examine '..
upport movement-foTerationtoward goal
2. act tobring inline withstandards,
evaluatepatieht ob-.
""i. new facts---+jectivis, and_nursing actions
-1825
Summary
In summary, the concept of nursing litocess is closely relatedto a general systems approach to goal-directed behavior. Althoughnursing process provides a systematic method for analysis Of theactivities of the nurse, one should be aware thatit does .not pro-vide a method for analysis of the needs of the client of nursingserveces. It has developed from the early approaches to planning.nursing care yhich were developed during the 1930's at Yale. Eachof the elemedts of the nursing Process overlap and interact withthe others in the real world applications of nursing care. however,differentiation of each componeht shouldeventimily result in,.clarification of their interrelationships.
0
THE PROBLEM-OR'_ ENTEDM2DICAL RECORD (P01.43)
Introduction
The problem-oriented medidal record is a system for the docu-mentation of patient care. It was first presented by Dr. LawrepceWeed in the mid-1960's (Weed 1964). Essent±Ally, it consists offour components of the medical record.t
40*
26
-1g-
I 4 , .
FIGU#E 3-
THE FOUR COMPONENTS OF THE PROBLEM - ORIENTED MEDICAL RECORD
e
1. Data Base C 2. ProblAm List
3. Initial Plans 4. Progress NotesSubjectiveObjectiveAssessmentPlan
These four components are the basis of the problem-oriented approach.In addition, the inclusion of a flow sheet is often presented. Thefour components consist of:
Data base,--This element provides the method -and form forgathering information about the patient.
2. PAblem list' is the 'res t of organizing, thenfOrmation gathered into:meanings. the list of defined
patient'prob4ens-. Some authors have discussed the valueof adding a list of assetsticxr-resources.
3. Initial plans.--An initial plan for each problem is includedin the problem-oriented recerd-(further 'planS, are to be
4
included,vitbin each progress note). According to&thissystem, initial.plans,are made for each problem identified.Hmiever, a valid initial planmight'be Vast of "no inter-vention apprppriate at this time."
r
4. Progress notes. This note provides a methtd for dealing withthe Ongoing response of patients and allows for the revisiolof the provider's apsessment and plan. It includes the.following elements in 'its often cited "SOAP " -note:
Subjective indicators of the patient'.s condAion;
. Objective indicatori o./f the patient's condition;
V 7.
.4
I k-20-27
. Assessment of this information;116
,Plan, based on the revised or reconfirmed assessmZnt. 1
The Anitial, basic flue of the pr hlem-eriented record.is that oforganizihg the information in a patient.recoid, The chaos oftheprevious "source-oriented record" is equently citpd throughout theliterature.
.
1.4,Other frequently.ci1ed assets of the problem-ciriented record are
thatit:
1. Enhances interdisciplinary communication,
Facilitates sharing of information with the patients (they'can be given a problem list);
.
3. Facilitates accountability to elients,anttbird-partypayers,
, "4. Enables audit <within the medical or nursingProfession). M
-Many of the'Same,principlei apply in the problem-oriented record as innursing process,approaches. Both are, in essence, methods of struc-'turing information toward more efficient goal-directed behavior.
The problem-oriented record provides the basis for a larger, morev,comprehensive, problem-Oriented system of which the problem-oriented
,
record is ore component (or subsystem). This more eomprehensilmapproadh is described by Walker, Hurst, and Woody in an article intheir book, Applying the Problem-Oriented System. It includes principles .
of practice, the problem-oriented' record, audit, and educational programs?(pp. 231-49). There is a considerable amount of overlapping of theterms and concepts thrOughout the literature as the record system grewto include a more comprehensive approach. Prescribed rules and principlesof practice were added to the use of the record- and developed into acompfekensive system for the-prorisioh of patient oere. Consequently,it was not feasible; nor Wei it the intent of this review,`,0to Organizethe literature from this point of view.- Therefore, forthe purposes of
feview, the term "problem-oriented .system" is used to describe a11.es of development of the problem-oriented record:
1. The pralem-oriented record as a system;
2. The Twoblem-oriented record .s. facilitator for audit andeducation;.
I.
I.28-21-
i.3. The need for defingd data base, foIerles, and finally,
for " -principles of - --
4. Thelproblem-oriented record system, including principles ofpractice, the problem -- oriented record, audit, and education.
]Nokground
re\
The beginnings of .the p lem-oriented system were pUblished by(Weed in the Irish Journal of cal Science in 1964. Inrthis
article, Weed presented the need for standards ouniformity and comr!
pletenessriuthe medical record and "rules" for order and discWineof the medical record which resenike the later components of the POMR(Weed 1964).
Basic themes that recur thrdughout the literature on the Weedsystem are raised in this first, article.
1. The chaotic nature of source - oriented records,
2.
3.
The need for self- discipline,.
The problems of "cooktbook" and memory -ba sed approaches tomedical education,
4. The need for audit,
5. 'The need fOi public accountability.
Two years later,.in 1966, 'Need` presented his new approach to .
medical teaching at a conference at the Duke University School ofMedicine. This paper was published in Medical Times the same year c(Weed 1966) and in Resident Physician'the following year (Weed 1967)..The elements of the record presented in this article include. a.
'numbered problem list; plans;Alumbered according'to the pr9biem list;and progress notes, similarly numbered. A flow sheet is presented,
0 although'it is not identified by that name 1Weed 1966 and Weed 1967).ft
In 1968, Weed's "Medical Records,That Guide and Teach" waspublished 'in a two-part article in the New England .1.4furnal of Medicine.The first half of the article focuses on a dhiription of the systemand the values of the problem- oriented record in organizing medicalrecordp. This A-tiCie adds, the concept of the computerized Medicalrecord. Computerization further strengthens the argument fop the needfor an organized approach to medical recordkceping.. The "problemslist' (sic) is mentioned in quotation marks, and it is stated that itis not static, but rather a dynamic "table of contente.for the patieht's-chart.
a
-22- 29
,
4
Differentiation between active'and.inactive problgpt .is made.An example of the "flow sheet? is provided.mnd'labele4. It is alsoStated that "Many chronic difficulties are best understood and man-aged by relatiox of multiple variables over time," The complexityof living systems is further recognized in the statement: "Theuncertainties -inherent in complex biologic.systemq make titled-pror-teas notes the most ,crucial part of the medical record." The assetsof computerization of the medical record are 11.6ted as thoroughness,retrievicki?itY,,efficiency, son,econoMy Need 1968, p,_599);
_ , ,
-s) 1
ti- In the second - section this article(Weed 1968A) published ,-,in the follaiing'issue d?the journal, the focus is on the value of.!,"tbe proble-oriented record for: -',
1. pK3ng.problems-in conteril%-.
,--.-
2. IOreasing'the efficiency of the record in assisting the' physician tp.liselect priorities;'
.:...,^ N :...
3. Increasing the continuity of care (differe*pbysicians inthe outpatiediepartment-who see the patient 1411 havethe same information, via the record); -
4. Educating, physicians;
5. Establishing a link between education, 'audit, and patientcare;
6. Establishing a feedback mechsasm for the physician'sown vork.
4
.#,
The understanding and management of any one problem require aknowledge of the presence of all of them: The need to recognizemultiple, interacting fact9rs in conteit'is.considered. Dr. Weedsteed: "Physicians must assume the leadership,in pro'4ding eachpatient with a total list 'of problems, irrespective of who in the*medical hierarchy provided the data,and in seeing that
_th erapeutic
action reflsets sane perspective on the total needs of the patient"(p. 652). Much of this artidiedeals Iiith'bomnuterzition and willbe dealt with in the section on the cil0Mtouteriied problem- orientedrecord.
., -,
'Weed's art "What Physicianiliorily About:. Hof To Organize.Tare of Multiple blem Patients;" vas pbblished in Modern Hospital(June 1968). This article describes the islue of a medical recordwhich is organized around a numbered-"problem list" which serves asa dynamic tableOf contents for the patient's .chart. The focus isthe physician's need for a method of manizing'information relatedto multiple iqteracting patient problems. There is a hint .of Weed's
. .
...
,
s.
0.;
-23-7 -
6dynamic style of presentation and aof this system to a specific patien
-.
exwiple of the values care (Weed 1964:
4111!if:
General Descriptions f the ProbTemrOriented System
4,,N
Overall -Detcrintions, Cone ts, PhilosophyL. '
Basic Introduction the Problem-Oriented System. (The.firstredition of Weed's book, Medical Records, Medical Education and PatientCare, was published 1n ,969. This took is a clear and simply statedpresentation of the trOblem-orient4ed record and of each of the c6ponents (data base, problem list, initial plan, progress notes, flowsheets, and disCharge summary). It provides a clear and valuableintroduction to the system. /
The publication of Wged's book vaif011owed by an: expandingamount of literature vith regard to the problem - oriented record.Many authors condensed the principles, of the problem-oriented recordand Ablished these in their State medical society jomrnals. Othersreported the516experiences it iniIiating or app the principlesof the problSt=oriented record to different p t±ce Settings or tospecialty areas and reported their experiences.
Three other basic and frequentlF cited books by other authorsfollowed. Born and Cross pub?.ishgd their book on the use of theproblem-oriented record in their group practice in 1970. Thrst andWalker's book, /The Problem-Oriented System, vas published in 1972
and. expanded the concepts of the problem-oriented record to includea whole approach to medical education,Itudit,-and patient care, as
implied in Weed's article in the New PmgTand Journal of Medicine,which stated that the problem-oriented record_ established a linkbetween 'education{ audit, and patient care.
This book was edited by Hurst and Walker of the Department of4dicine of Emory University School of Medicine. It consists of --
articles viitten for thii book or reprints of othersartiples by themajor proponenta,of the system. Sections on "Background Information;""Practical, Educational, and Nursing Implications;" "Ambulatory Care;""Private Practice and Continuing Educhtionl" end "The Computer and theProblem-Oriented System" are 'included. The two azticles in the briefsection on nursing vill be considered Under the section on "Nursingand the Probl ented Record/System" in a'later section of this,bibliography. . ,
AIL ,
Walker, Hurst, and Woody's Applying the_Froblem-Oriented System(1973) states as its purtose sharing nyith a vide audience the
s.-24. 34.
S
astonishing variety of constructive and innovative chan4es in health, carp= delivery that have occurred with the adription of the problem-
o'riented system" (p. xv). The overall Philosophy and goals of asystem of health care as applied by different workers for differentgoals provide the content. The 10 sections, each including severalarticles" by different authors,' are:
.
I. Introduction.
2. Problem-il-iedned Practice in Vermont. This section reportsthe exre*ience,of the group practice in Vermont.
3. Problem-Oriented Prettied in ..y den Highlands, Maine.
Communitylkealth Care Delivery: People and Tech!rques,.
5. A Review.
6. Quality Control in Health Care Delivery.
F
7. Education.
8. Hospital and Specialty Practice.
9. PatholOgy..
psychiatry and Psycho-social Aspects.
This book presents the reports of two conferences on the problem-oriented system which were 'Aid in 1972 and 1p73. Consequently, thelevels of sophistication and the attituaes of the different authors'are very-miixed. One conference was held for.plrysicfaas, the otherfor nurses. The book includes both a sophisticated article othecongruence of problem-oriented and "nurging process" approaches and ,
some extremely 'unsophisticated approaches to the role of professionalnifrsing written by rhysicians. gespite its very mixed leveltof -
quality,- it'is probably the best single resource with regard to thebasic principles, range of applications, and presentation of the assetsof the' problem-orientedisystem. Spe4fic articles or sections will bedealt vith separately in the sectiond which follow.
,,
t
Neel on an Ellis' A Syllabus of PrObIlem-Oriented Patient Care washpublished) in 1 4. '.he initial purpose for the book, as stateebx
the authors in he preface, was to serve as a guidebook fornedical+students, staff. and ether health vorkets at Duke University. The ,stated goal was: "to outline a method of patient care based on alogictl and intellectimily ordered record that demonstrates scientific .
precision of thOUght in the daily%business of+patient care and dis-courages our conte'n with half truths."
2:4.11' . z. 32-25-
goe
4
cThe authors' view of the problems- oriented record is ample
direct; and borst. Marysee it motivating principles a to by able-to knov it any particular all the patient's health problemsand to structure the record so that it = =ists in the alleviation ofthose problems" (p. mil. The book incl an initialostatement of.philosophy, vbith is clearly-identified d'descriptions of each ofthe commonents of the problemtzortented The ex Ales providedare primarily from the authors' ovn'area of practice, vbich is endo-crinology.
TOston'sPrOblem-07A.ented 14.edicaf Record Concepts (1974)its purpose as the explanation in simple#terMS of thxpibblem-=edsystem. The author envisioned the PDHR.as a device for:
1. Simple and accurate accumulation of patient data;
2) Cr*---Imication of thatsdata among the various members of thehealth team;
3. Evaluation of health care.
A section on the nonproblem data check sheet for routine daily patientcare is inTluded.
eed's recent book,-Your Health Care and How To !sage It (1975),vas vrItten td.oriect the public, 'patients, 4nd potential= patients tothe value of the problem-oriented syster:a. It includes a deidriptionof thecomponentp of theproble--,-orimted record, considers. the issueof giving the patient his awn record, and.discustek.the problems ofspecialization as opposed to generalization. It alio discusses theneed for establishing rules with one's physician as to vben to phone
r.him; audit ann-the xplue of the ROHR in audit.; and tie problems of .
medical education, elanfidentiality, basic research, and priorities.medical' dare.
Schultz, Cantrill, and Morgan's jieleription of the computerizednursirt unit and extensive appendices,.inclmiing a computerized healthquestionniire? are also included. This book aastftes a certain amountof sophistication vith" regard to issues in medital-care educationon the part of itt readers.. As vith` any other book for rs, it,should be read befdre assuming its suitability for any vidualconsumer of health' care, 1r-
;Jui-artici; attributed in bibliographies-to Dr. weed is
an intervigv with him but Was noi'vritteh bybdar Personally. It is,'however, anaryeanus presentation of many of the, current issues re-
- gardiag the problem-oriented ajbLes6 It offers a gieat deal of Juror-ration, both that. vhich ties been..publishri in more formal approachesand.thAt'vhich is. informal. If one has never heard Dr. 'Weed present
his syszen in person, it -is almost a"..must" ear brientation/o his'direct, logical,,colorful,&and cho:17teic sty4e; for examplerissuesof specialization: "trouble is . e' ire never had a renal Mule
alone;" informing thI patient of wbal'.'his problems are, lowthly were determined, and what the plan is for each mroble6:\ "most of'the patients don't know what . . 1 we're trying to do;" audit:- -"youhave o define the rules." Au4i-t, according to Weed, should be "con-
Aepeadent" and be geared instead to thorolleness, reliability,1,-
, and logic (Weed 19731; 0
4
Len;
occur
au`.ho'rs have
a record:
Vwith discreet comrAnenJ'of tiie roblem-
Hurst 'Haw Des One Develop a Defined Data Base," 1972) and771'ant*"Data Ease Collection.ond Problem Fo_ ation inPsychs-social Care," unpublished, n.d.) wrote out defininga iata 4g,:asA.
..Mez-- wrote several art es regarding the nroble list. Carrand H-zrs't 1.19'3,.used an ..rrow to indicate than4/.problers havebc.en soled.
Mar 'Doctor_y -e
matiert
Plans in POMP System; item: Patient Education,suggested the use of snecifio plans for.
-. 'Mazur 7..oughts onn.d., described the:sp-rne-,4d$. S.
the Soaping of Progress Notes," unpublished,"SCA= mote, while others (Ellis, 1973;n and Wood, 1971) discussed flow sheets.
Advantages, Disadvantages, and/or the Controversy Overthe Problem7Oriented Medical Record System
..a)Peviews ani responses to Weed's "Medical P ols,.. Medical-Educationand FWent Care". (1969) followed its publication. Many articles andheated letters to the editor occurred in response tothis and otherdascriptioofthe system. Hurst's."Ten Reasons Why Lawrence Weed IsRight" (1971) provides an'enumeiation of the valUes of the problem-orietited record:
411$
4It encourages sound logic.
2. ft enables one to use the record as efficiently as one uses adictionary. .
3. It allows the physician to communicate his thougts to nursesand (others) . who are assisting him in the J5friAdigte care
4M.
.of the patieA..C'
4. It enhances the continuing education of the physician and all,49 assist himi in the.care of patients.
5. It prepares the student and the-physician for the computerworld that is coming tb our rescue.
6.... In group practice, it will be the common bond between severaldoctors and a patient. ,
7. It will make,it possible to do more accurate cliRical research.
8. It will eliminate ward rounds . . vhich'can become patientrounds end not lecture rounds.
_-9., It encourages a more meaningful way of talking about patients.
10. Patient care is improved directly or indirectly-by each of thenine reasons listed above.
gOldfinger ("Critique From a Believer," 1973) began hisciltique ofthe problem-oriented system by stating that its followers consider them-eLelves converts to an idea whose time has come and vho will brook noheresy of proposals for furthgr evolution of the system. He raisedissues of style versus substance as the focus of dare, and stated thatthe "emphasis on compartmentalization . . . has the potential of negatingsynthetic thinting" (p. 607). He also stated that the data tpe cannot-be a discreet section'of the chart, that in fact, exery progress noteYields data that constitute a base for=further action. He-objected tothe inconsistent qps -1ity of entries byea "variety of allied health per-sonnl" which add bulk -without meaning. The-issue of "intuitive skill,",the quantum leap from bits of,information to the meaning of infbrmation,- was raised. Its compatibility with coiiputerized approaches vas questioned.
Finally, Goldfinger (1973) questioned the, claims that the prob)..em-oriented record will greatly facilitate audit. He-stated that gaps inall recorcTh Exist. Most,audits are designed to measure Biller-1s therea problem list?" "Are progress notes problem-oriented ") rather thancontent. His copclu§,ion reiterates his support of the problem-orientedrecord and the contielbutionathat_it has made, but also states his con-cern that it may not bethe'panacea that its believers consider it to be.
The same issue of t his journal carriedlgurst,Aalker, and Hall's
rebuttal of the GOldfinger article, "More Reasons Why Weed 11 Right."They compared the problem-oriented record vith a car--a tool tb achievea stated pulpose, even though not everybody drives it in the same way.They responded to Goldfinger's Statement that there should be more earphasis on substance rather than style by stating that-the POR enablesone to determine instantly the level of understanding held by the writer
:35
-28-
of the note.k
These authors resDpnded to Goldfinger's objection to sorting outa discreet data base by stating that an initial data base must be de-fined, and Carried out every-time. They responded to the issue of thegreater amount of time needed to identify pertinent data by statingthat there are studies to determine the difference speed and accu-,racy of information retrieval from traditional versus problem-orientedrecords. They anavered the issue of audit by differentiating audit forthe presence of all the elements of the record and audit according' to -
standards for the management of specific diseases. They concluded bystating that if the POR is not used 'properly, it will be impossible tocorrect deficiencies in medical logic and patient' care. A lively group
. of letters in response to Goldfinger, Hurst, Walter, and Hall appearedin g later i ue of the same journal.
. 16. Buchan 1973 vas "bemused" .by the consideration that changingterminology is going to advance medical education and medical care.Similarities hetveen the concepts underlying ir.d and new words werenoted: problems and complaints, subjectfve and symptoms, objectiveand signs, and.asses5ment and differential diagnosis. He:feared thata cult cf the recora could vell see the patient lost in the process.
:ssenberg and Vii;e11 (973), junior medical students from dory72tiversity, were taught unter the problem-oriented system and supported'
. it. They stated that the identifi'cation of pfUt5zs is.oely the begin-ning 'of a process of synthesis. The FOR not only entourages thissynthesis bit also demands it.
Goldfinger ("The Problem of the Problem-Oriented Record," 1973)responded to all of this by stating that while all the arguments pre-sented are compelling, he remained pessi*gtic. The motivation anddiscipline required for the griper use of the POR may be lacking inmany of its future uSters. Skilled observation, intellectual honesty,and healthy self-criticism may be more important in medical educationthan the single goal of recordkeeping.
/,
In another journal (Annals of Internal Medicine), Feinstein (1975)differentiafrd between the valued of the problem-oriented record itself(the freedom to idenil-fy-problems as they exist without using medicaldiagnostic terms, the inclusion of'a format for patient education as anintervention, and the method for organizing previously random re-cords)
from the apparent advantages which arise not from the system, but fromthe enthpciasm of its users. He stated that "illusory adypntages"retilTfrom the vigorous supervision of the system. He felt that Con-tinuity of care, quality health care, continuing audit of patient care,and interdisciplinary coordination are not essential outcoth of the useof the problem-oriented system.
41
Feinstein argued_that the problem list fragments the patient no less
. I
-29-36. 6
fa
N16
than specialty areas do, and raises the question of releience of infor-mation in an unedited data,base. He believethat the emphasis onrecordkeeping, rather than on strategies of patient care, is a n4gativefactor, of the problem-oriented record. He objfiated. Weed's consider-ation of the MMPI in an automated data base, as a me for the patientto obtain "immediate, sympathetic understanding of he forces withwhich he or she is struggli6g." Other issues r ed as disadvantagesof the system have included: The reader may wader whether the
`'problem- oriented records work as well as it is claimed and ifbethermaintaining, them does take too much time ("The Medical Record: CoverUp or Teaching Tool," 1969).
Although Carson (1973) Agreed with the necessity of the Weed ejkemto accomplish needed changes in medical care, heiptated that the easeof computerization and the value resulting from it are not necessarilysynonymous., He also suggested that the ability to comply with the sys-tem, rather thant quality of ;medical care, is audited, and he vasconcerned about ifting the focus of providers from findimental prob-lems to the record. Hawkins (1973) voiced his concern that the problemlist Can offer a false sense of security, but stated that the problem -oriented record is better than apy,disease-oriented medical record.
The National League for Nursing (1974) listed both advantages anddisadvantages of the system in their book, The Problem-Oriented SystemA Multi-Disciplinary Apnroach. The disadvantages include:
1. The mechanics of recording information requires too mach timeinitially,
2. It quickly uncovers an individual's deficiency in informationand assessment.
3. It may be threatening td-allied-health personnel who enterthe main arena of recording their contribution to patientcare. , t.
4. It requires the discipline of analytical thought (p. 10).
Theesdvantages of the POMR listed in. this monograph include:
1. It establishes the concept of patient care, not just nursing-.care or medical care.
...
2. It allows all partiCipants in patient Care to contribute,meaningfully to the record.
3. It rovides documentation of comprehensive care (or lack of it)the continUity of the`data recorded.
4. data become problem- oriented and, terefore, immediatelyrejevent.
4 3`7-30-
4
It prevents the duplication of data:
6. It prevents .oversight of essential information that needsattention. 4
7.. It permits easy audit--Ameefficiency, effecti/eness, andperformance.
8. It allows ready acceas to specific\prOblems for audit andtearbrini.
It identifies individual and staff needs whiCh provide'feedback fdr continuing education programs.
-Additional assets ofIthe system were presented in Lancet ("Problem-Oriented Medical Records," 1972). We have no rational procedure forclassifying the data of human illness. Weed avoids this by dealingwithproblems and by identifying these problems*_on-a level aonsistent,withunderstanding. Clarity and honestty in defining problems' should applyto behavioral and social problems no less than -to physical problems.
. .
Cross (1971) identified the POMR's qi3Antagei of honesty of "g-nosis, the opportunity to explain deviations from the usual managementof problems to the patient, and the provision of, a more adult-adultrelationship with patients. Twin (1974, 141. 22-28)-stated that the aysx-tem is so logical, so basic, so simple, and so adaptable to the computerthat one wonders why none of us thought of it before.
t'aNumerous letters. and art icles support thh,problem-oriented record.**
Most of these points are covered in Hurst and Others,' two statements,"Ten Reasons," and "More Reasons Why LaVrence yeed4s Right." Inaddition,- most of the literature regarding the congeptb and philosophyof the problem-oriented record includes stat&ents of the value of thesystem, especially as it app1Rb to a specific function or setting.
Pgifferling's discussion (1974) includes reasons for physicians'resistance to the POMR and humanistic strategies to encourage theiracceptance of it. The new record should be introducedfat a time whenthe staff feels that record reorganization is necessary. Strategies' toachieve acceptance of the dew system and to minimize resistance wouldinclude:
1. Disseminate information about the POMR;
ti 2.4 Provide a forum for discussion;4
4r;
3. .Indite ail staff meters to participate in the decisionmaking;
4. Focus on the similarities between the new system and-thetraditional system.
The factors whichjaay delay Canvereion are listed. Three major factdtsin physician resistance are:
1. The threat ofrceived infringement on the physician's domain,
2. The threat'of substituting problem titles for diagnoses,
3. The fact that physicians are not trained to state explicitlythe method they use to arrive at diagnoses.
Initiat'ing the Problem-Oriented Record_ and/or System
Methods for Initiating the Systel,
Bjorn and Cross (1970)-described the initiation and use of theproblem- oriented system in their group practice. This book is a fre-quently cited resource for physicians. -Burst's'vHow To Implement theWeed System . . ." (Hurst and Walker 1972) provides a:description drthe cdovonents of the problem-oriented record and rules for their use.He discuSted the obstacles to acceptance of the record, which heidentified as being related to:
1. Acceptance of innovation,
( 2. The mechanics of the system,
3. The quality of the problem list.
_Wakefield and Yarnall's Iqlementingthe Problem-Oriented MedicalRecord (1973) is a report 'of;.ad tokftence that was held in Seattleduring 1972. It includes the-rationale for initiating the POMR, adescription of the system, and future'ilmplications (occputeril'aion)'in addition to the methodology for imtlementing the system. The sec-tion on the methodology for implementing the system includeb consider-atiOn of (1) staff education, (2) design, and (3) audit. The authorsstated that the flow sheet is valAable whenever the interaction ofvariableA is critical. They slob stated that the record is a. means,not an end, to improved comantiication between health care providers toassure high -quo ity comprehensive health. care. The unique characteristicof he POMR is its explicitness.
A sdrvey of medical record librarians in 18 hospitals using thePOMR indicated that factors were particularly important for successin implementing the new system (Wogan 1971):
1. Involvement of the medical record librarian;
2.- Planning for followup and audit of results and for workableforms;
39
c.
3. Education-orientation of those who will contribute-to the''system;
4. Follovup identification of areas of strengths and weaknesses,and planning for m'ethods,_to correct deficiencies.
Esley (1973), a medical record librarian, presented a specific methodfor initiating the system, including a discussion of its legal aspects,and pvcvided an extensive appendix of fotms.
Reports of Initiating the Problem-Oriented Record and/or System
Several articles in Walker, Hurst, end Woody's Applying theProblem-Oriented System (1973) deal with the initiation of the system,.Tufo and others (1973) described setting up the problem-oriented systemin a group practice in Vermont. They considered the patient to be amajor, untapped resource in the health field. They described their useof patients to audit their awn subjedtive data and their belief thatpatients have a*right to their own medical information. This revolu-tionary and valuable concept is applied in their practice.
7
McCracken (1973) described her process in setting up the problem-oriented record in a family practice clinic. She included .forms,patient orientation, and a medic's.' history questionnaire in her article.Mazur (1970 described the process of esfablishing the problem- orientedsystem in a State-)psychiatric.hospital. He included a brief discussion,of the strategies/msed and methods of Worming the staff and the public-in initiating the use of the system.
Asp and.Brashear (1973) discussed the initiation of the problem-oriented system in a private hospital. The time required to initiatethe system in a private practice was documented by Frooth .(1973). Threehundred records were converted to the problem-oriented method atthetime of the patients' scheduled visits. The conversion took about 5minutes per record and was' accomplished during broken appointments orduring the time'that the physician normally spent waiting for the patientto dress or undress.
Applications of the Problem-Oriented Record
Walker, Hurst, and Woody's Applying the ProbleM-Oriented System(1973), reviewed in the general introductions to the. system, includesapplications of the system for various purposes, in various settings,and by various health professionals.
4Applications of the Problem-Oriented Record and/or System for SpecificFunctions ,L
%,
4 -0
-33-*
tt
The logical organization of the problem- oriented record providedNaltbash's for maintaining feedback to the health care providerbrusimg the '
. system. Two uses of the'POS, audit and education, are based in the .
single concept of pioviding a 'eedback loop to the provider& of Care.*'Algorithms provide a StructUeellse't. of guidelines for purposes ofguiding the deciltgnmaking,process care, and facilitate audit of line,verformance off the person provi that care.'
Audit. Donabedian's (1966) classic article on evaluating thequality of medical Care is not directly related to the problem-orientedsystem, but'it do4i consider basic principles of evaluation. He
"differentiated between threea
apnroache to evaluation:
1. The outcome of care;
2. The process of care;
3. The process, settings, and instrumentalities of care.
V
Donabedian identified theAconfounding issue of the differencebetween the recording of care and the actual care itself, an statedthat these two distinct aspects can be separated when another sourceof information, such as the direct observation of the care itself, canbe provided. Two uses of the POS, audit and education, are based onthe single concept of* feedback. As a result, there is considerableoverlapping othese two concepts in the literatures and considerationof any given article.under either topic is often purely arbitrary.
Weed (`.'Questions Often Asked About the Problem - Oriented Record--Does It Guarantee Quality?'," 1972) described tee problem-oriented recordand its components, then discussed the four characteristics which hebelieved should be audited and which can be pbserveff when'the probleart 'oriented record is used, These are: (1) thoroughness, (2) reliability,(3) analytic sense, and144-efficiency. article is directed tothe audit or physicians and medical st.-nts, but the principles listedabove need not be limited to audit of -dical performance.
Weed's ("QiialityliControl and the Medicdl Reciell,1 1971) basic,
philosophy, concepts, and principles regarding audit are presented.Pour premises of the irblem-Oriented audit.of the physicialf are given:
ga ,
1. All the data after the data base must be associated with a'specific p?Obleni.
*
g. All the data on any given problem bast be easily retrieved insequence and with complete currency.
, .
3. Conclusions will be much more difficult Vten,there re con-comitant problems in the same patient and must then "be deter-"ed
41'-34-
.7
cr*
a.. .
1L Procedures 2 and 3 can be followed with computerized data. 6 .only (pp 257-58).4._
- -
Weed statel< "a physician -should be auditegalpsterminehe is a good guidance system, responding intelligently to-feedback
,
informatiort in a very'vell defined, though peceparily incomplete setof measurements. The shape of, his path through, the difficult biologicalsituation is generated as he goes and is not. known until the input stops"(1); 104)% In another article ("On Being Responsi*e and 'SettingPriorities," 1973) Weed differentiated between'the audit of individual.performance and the audit of the system. He presented criteria l'az_auditof the data base and discussed factors related to audit of the problem
`' list, plans, and progress notes.
Weed alSo stated that the mindless'application,of criteria may leadto disregard of the patient's uniqueness and identified that specificcomponents must be audited in the.context of the total ant's prob-lems. Hurst., in his article, "The Problem-Oriented Record and theMeasurement of Excellence" (1971), stated that rules provide the frame-vo thin which excelle e can be judged and achieved. He failed to
. differ tveen me cal care and the medical record)
Burger, Bjorn, and .ctoss (1973) stated that-the 1)asic ;meatsfor au , according to Weed; are:
.,
o\
41111The system must be described;
2. The users of the system must be audited for performance vi'thintherts of the system;
3 The system itself must be audited and updated through analysisof the.datp. it generates.
Thr e approaches 'to audit are described. Audit can be based on:
. Arbitrary criteriaa problem;4
2. Outcome analysis;
3. Behavioral analysis of thoroughness,'reliabilitn'analyticsense, and efficiency.
The last is the most approp ate, and its at the PROMIS clinic inMaine is described.,.
Satzer (1973) critiq an "Article by Lipp. Altho pitzerpvas in favor of the problem-oriented system,'he s with Lipp's.focus on the'use of the POMR for process audit. s major objectionwas the inability to discriminate between writing a good problem-.oriented record and providing goOd care. In addition, there is.the,threat of treating the record, rather than the'patient. On,e systems
4246
7
are installed, the tendency is to "let them grind" whether-or not theysolve the problems for which they were designed.
Lipp's response ("Authbr's Reply,"19'73) to Spitzer's -criticismidentified the potential' -foi- differences_in perception'by (1) the
.patiebt,. (2) the therapist,'(3) the record in the-chart, and (4) a Jhypothetical objgriV,Filbseer. Any audit system based on process'will bave'tbis difficulty;_it is not limited to the..POMR. Goldfinger's(1972) letter responded to -an article by Fessej_ and VanBrunt ("Assess-ing'Quality Care From the Medical ReCord," 1972). It suggested that_Weed's "atient Educations' section of the PONE would have considerablebearing on audit design, especially in conditions in which the physicianhas a limited,impact on the outcome.
Education and continuing education of Physidans.--It is not theintent of this review to evaluate literature with regard to medicaleducation. However, some-of the concepts used in this literature arealso applicable to clinical nursing education. One of the main ssietbof the problem- oriented record is the accessibility ofOe student's1pgic, presented in the "assessment" component of the (progress note.This early article by WeedWA New Approach to Medical Teaching," 1967)presents several basic premises:
1. The medical record can be used as the basis for the quality ofpatient care;
2. The medical record can be the basis and primary focus ofclinical teaching;
3 Basic science Bain teach the student how to:',
Collect data,Work on one thing at a time,Write up the problem,Conduct a-good audit,Proceed to-the next problem.
L
A later article by Weed ("The Implication of the Problem-OrientedSystem for,Medical Education," 1972) condemned ry-based education.Weed identified and Attacked' old premises in medic education and pre-
. sented his new premises in his article in the New d Journal ofMedicine ("CPC's as Educational Instruments," 1971). lhe old premise ofthe importance of memory of medical information should be replaced with
the'capacity to define problems and to find and use knowledge effective-ly. The old premise of the teacher's fOle of communicating informationis contrasted with the haver role of the teacher as disciplinarian andauditor. The old value on resources of academic settings for experience.-and equipment for basiC research is contrasted with the new value on thestudent's own resources--his capacity to learn, think, and solve realprOb/ems on hiiown. {Computerization of information which was previously
43-36-
ti
'N.J1.stored in human memory permits 13. curriculum which will facilitate thestudent's development in other areas.
Deve6pmest of algorithms and supervision of Physicians' assis-tant.--Several authors have dealt with the development, or use ofalgorithms which they used to train physicians`- assistants. There islittle or= differentiation betyeen the role of a pllySiciensi assis-tant and the nurse clinician in this literature, and the titles ofthese different roles are qfteninconfused. However, all of the liters,-ture (except for Mazur's appoaFh to algorithms) describes, in essence,physicianST- assistants' roles, or perhaps at best, 'the dependentfunctions of a techniCal nurse'. */
.:.,.
.r ..6
Burger, CrOss, and Bjorn (1973) from the Hampden Highlands, Maine,group, outlined a format for iniorporating episodes of acute self-limited illness into the framework of the POMR/lba algorithm for sorethned is presented. They staled their philoscOV that: ."We believethat non-physicians can providl patient, care without direct physiciansupervision only when clear, tbjectiye criteria can be defined to guidetheir actions."
#
Mazur's memoranduM ("%eed Without Tears-. . .," 1972) presented-three algorithms for:
1.' Ranking active -&Alems',
2. Ranking inactive pi-oblems,
3. Consdlidating problems.
sironmaking process and leaves room forzthe,selection of the r ev
Ma 's approach to algorithms is congruent with a,profession
criteria to the patient and to the.Rrogessional.,
Applications of the Problem- Oriented We6ord and/or System to Specific',Settings eilad Services L..,
ik. ...
Priyate.practice.--A large t-...
of' 1 .erature that deals withthe *Application of the MIME to AK2e p actice 511 not be discussed.
, ,AmbulatOry cared The literature egarding applications of the
problem-oriented reIord and system t bulatory care reiterates itsassets in these settings. A
.
.S 4,p
Rehabilitation. --The literature that deaf with applications of,the'prOblem-oriatited record and system to rehabilitation offers ,'several new conapts. .
.. .
-
.r.
44tft-37-
1'
0' #
' "'6.
*Dinsdale's article (19/0) mentions that Vle previous emphasis ongoal setting has shifted to the definitiOn of specific prbblems. Goals,he stated, emerge tor)interacting groups of problems. Milhous (1972)stated Ma the'team conferedce is a powerful force for uniting patientsAnd, staff. In Applying the Problem-Oriented System,l'he noted thatpatient education was improved; team members unite around the patient,.rather than according to their awn professional identities; and studentteaching was ,improved. Patients were given.a copy of their own prIlemlist and the initial plank for each problem.
-
Psychiatry-and the psychosocial aspects ol care. - -There is a con-siderable amount of literature regarding the use of the problem-orientedsystem in psychiatric settings Or for the psychosocial components of .
patient care. The general tond'of this literature considers the problem-oriented -system to be no less valuable in the psychosocial aspects ofcare than in any other form of care. Grant's work deals primarily withdeveloping a data base for the psychosocial component of patient care,regardless of the setting.
Concerns.have been raised by those who au cautintig-in-theiracceptance of the use of this system for psychosocial cafe. Heavymedication or certain behavior therapies might mask individual clientproblems to the detriment of the patient's *total well-being. Aproblem-oriented audit could produce favorable results in such instances.Another concern was seised by those who object to the use of'a standardformat such as the Minnesota Witiphasic Personality Inventory,as ameans of obtaining a psychosocial data base.
' Finally, psychiatric diagnoses as problems are not functional.-Traditional psychiatric diagnostic categories offer little informationregarding the unique problems, experiences, histofy, and method oftreatment for clients. The argument for a greater degree of specificityin identifying problems is made by Abrams, Neville, and Becker (1973)Their article deals with the psychosocial components of,oare-in arehabilitation setting. The authors devised guidelines for use withpsychosocial problems. The problem statement must be as specific and
. objective aspossible, and include the way in which the problem inter-feres with this patient's or another's rehabilitation. The main focusof this article is toward increasing the specificity of the statement
-of problemS toward more humanistic care-of patients.
Gilandas (1972) stated that progress notes recorded by team mem-bers representing a variety of orientations are the most importantelement in the problem-oriented approach. Theses he said, serve ascorrective feedback._ He also stated that the physician must use hisskills to integrate the recorded information and that he must be awareof problem interaction. In a later article (1973), Gilandas provideda sample problem list and treatment plan. He mentioned the need torecognize the patient's assets and strengths, as well as his probleis.He believed that although the problem- oriented record is not the solo-
45-38-
tion to all problems, it could take the mystery out:. of psychiatry.
.Although primarily related to utilizatiop review, another article
by Gilandas (1974) considers .the application of the.problem-orientedrecord to'psychiatry.' Recogaitidn Of the vide variety of techniques -;_,
and theories used by professionals in the psychosocial area is counteredwith:a statement from Truax that the behaviors of effective therapists -are strikingly similar despite their different theoretical stances.
Grant ("The Problem-Oriented System in Psyc4iat i, 1973) provideda brief background of the use of the problem-oriente record in psy-chiatric settings (University of Oregon; Osawatomie State Hospital,ranas; and McLean , Boston, Massachusetts). He described the
t-a-components of compreh ive care as being (1) social, (2) medical(physical), and (3) Osychological, as well as ,including the interactionof these three faCtOrs. He believed that the problem-oriented recordseems to rely strong' y on a medical, disease-oriented model. He raisedthe issue of abstract diagnostic labels in psychiatry, which are notfunctional. He stated that people who are not medically trained "tendto resist . . . structure such the FOR" which "tends to discouragecreativity and idiosyncratic beha (p. 446).
In another article, alSo'in*Walker, Hurst, and Woody ("Toward a,
?sychosocial Data Base "), Grant argued for the inclusion of a..psycho-'social component in any comprehensive data base. Thefgneral areas for -
&elusion in such a data base are listed. Grant's ("Enthusiasm Nobubstitute for Hard Work," 1973) description of the application of the
OkDroblem-or4nted record to psychiatry and dit included a statementof the need for critics who work with the syst d who can see bothits advantages and its needs. In an unpublished paper prepared for theAssociation for the Advancement of Behavior Therapy ("ComprehensiveHealth Care Records, Behavior Based Therapies, and the Problem-OrientedRecord," 3973), Grant stated that the most useful way to define thebroad range of psychosocial problems is at a theo4Y-free, functional,problem-management level.
Two nurses, Hawley and Smith, worked vith Grant.(Hawley,and Grant, 1913) to initiate an audit system for psychosocial care at
. the University of Vermont. The article includes the following criteriafor audit:
1. Completeness of the data base,
2. Inclusion of problem areas indicated on the data base on theproblem list,
3. Level of specificity of the problem definition.
A summary of the results of the audit showed deficiencies in dietary,cultural, and legal histories (50 percent of the records had no data);
46-39-
economic, religious, and cultural histories (40 percent of the recordshad no data); and interpersonal areas (35.percent of the records hadno data
ayes Roth, Loagabaugh, and Ryback (1972) dealt primarily with, thevalue of the problem-oriented record in supporting the transition frommanual to computerized record systems. They discussed the value ofthe problem-oriented record'sjorganization as a method for facilitatingstudies within and between different hospitals; the definition of ple-
. cise, valid, and reliable diagnostic categories; and their forms oftreatment Their article, published tte following year (Hayes-Roth,Iongabavgh, and Po,back 1973), includes principles saieh have value abeyond the specific application to a psychiatric setting. It inclthe following topics:.
. Syne= analysis as applied to the mental hospital.
The crisis orientation of the mental hospital.
The functions and decisions within such a hospital.
The compatability of the problem-oriented record with theinformation needs Ef the hospital.-
How a hospital information stem learns and Vtilizatioreview:
Mazur's anpublished memorandum, "Weed Without Tears or Twelve ,
Easy Steps to Make a Complete Problem List," (1972) stated that hisapproach is rooted in A. Meyer's holistic approach to human life ex-periences. As a result of this approach, Dr. Mazur has recommended afist of assets to follow the problem list, a major innovation in theproblep-oriented system. He recbmmended the grem-oriented recordto his staff from the viewpoiet that it ii a for improving thecare of patients and must be adopted to fit patiept needs, rather thantrying to squeeze the patient into its format. He presented a methdd(lines connecting probles) for consideration of the relationship be-tween-problems. The notion of potential pidblems is balanced withthat of the potential for the resolution of'problems.
Mazur described an algorithm fox-ranking active problems whichinciudebrthe degree of threat to the-patient's life, the patient'srecognitidh of the problem, and its potential for positive response totreatment. An algorithm for ranking inactive problems is based on thepotential for,chapge (better or worse), degree of threat prepented,bythe problem, its potential for response to treatment, and the likeli-hood of its reactivation.
Mazur has stated (personal communication) that he believes-thathis major coaribution to the problem-oriented system is his concept
of a list of assets. This concept is presente0(in his unpublishedfrmPrandum ("Problem-driented Records . . .," 1972). The list Ofrassetsmay be organized according to the availability, intensity, or location
. of the 'resource. In "Coffee Break Questions" (1972), Maiur.suggestedthat Dr. h'eed's book had started a revolution and initiated a changefor the better. "Most of us are for it. However, we must not regardthis book as a holy writ containing dogms from which no departure ispermdssable (sic) . The POMR system is a tool devised for patientswith somatic illness. It is our job to modify this tool to fit-Ovr-'"-'needs in treating psychiatric patients." .Once again, he has statedthat we mist shape the form of the ?OM R system to fit the patient,rather than 'try to squeeze the patient into a preconceived form.
:n "The Problem-Oriented System in Psychiatry" (1973), Mazur pre-sented the reasons for the problem-oriented system and its basic workings.He found that the adaptation of the system to psychiatr)dhowed the needfor inclusion st: a:14t efl assets. He felt that ainegative attitude isfostered by the focuSon 1-.1,-oblems by both patient and therapist in thetraditi opal prqblem-7oriefted approath. The importance of strengtheningthe hea±hy pai-t of the person and mobilizing his resources is part ofens. "heeling" process. The construction of a list of assets providesthe solution to this problem. "The vital balance approach to. the POMRsyszen, integrating the 'catabolic' vector of the pathological 'factorswith the 'anabolic' vector of the health-promoting forces should makethE"Weed system acceptable to most psychiatrists irrespective of the'school of thought to which they may ascribe'" (p. 6).
Novelle's article (1973) deals with the applications of theproblem-oriented system tc psychiatry, the report of the institution ofthe system in a 2S-bed adult psychiatric unit, and the Specific adapta-tions of the zystem. Treatment goals and treatment plans are includedin the problem list. Progress notes include the staff's response to-the patients. in addition to the flow sheet, a progress chart includesprogress ratings by all staff and sometimes by the patie t.
Ryback and Gardner (1973) identified and eountered three issues inpsydhod5rnamic problem formulation:
1. Problem formulation in this area is so complex that crystal-"lization into a phrase may be meaningless. The answer to thisissue is the concept that the state-of-the-art may be.imprecis,but this does not argue against the method.
'The philosophy of viewing the patient as a list of problemsappears to ignore the patient's strengths and adaptivesolutions. This is answered by the notion that the patientseeks care precisely because he is symptomatic.
3. The problem-oriented format ignores the patient's basicindividuality and wholeness. This objection is countered with
r 4
4.
the author's observation that the more complete the problemlist, the mpre_cipiely:it approximates the patient's individ-Wity and trat-each problem is assessed and treated in thecontext of the other problems.
Sedhev's article (1974) presents a logical, realistic, humanisticapproach to the use of the problem-oriented record in child psychiatr,Psychiatric problems inevitably cut across other major areas of human
The
7ffunctioning or need. proposed that probl be categorizedinto related clusters and broad/ categories to deal h this.. It
is suggested that the degree of abstraction in problem formulation beboth specific yet allow flexibility for staff members. Harvey (19744considered psychiatric diagnostic "labels" to be nonfunctional in theproblem- oriented system and argued for objective, observablelehaviorsas problem statements. '
The Togas Veterans Administration Center report on the problem-oriented record (Pfifferiing 1974) describes the problem=orientedrecord and its application to the problems encountered in a psychiatricsetting. In psychiatric settings, data are more diffiCult to sort intosubjective and objective components. Therefore, a DAP (Data, Assess-ment, Plan) is used rather than a SOAP format for the progress note.This report includes Gilandas' "Problem Classification Guide," whichprovides a working list of problems encountered in patients withpsychosocial problems. Finally, Rothstein's letter (1973) argued for
,..
differentiation of'alcoholic problems according to the type and length ,
of treatment required. He offered the example of the treatment of anacute episode of intoxication, which differs greatly from that forchronic alcoholism or Korsakoff's disease. ,
Acute care and coipnsry care:--Applications of the problem-orientedrecord and/or system in acute care and coronary care settings consistprimarily of,,,Silverman's two articles. One of Silverman's two articlesis in The Problem- Oriented System (1972); the other is in 1221yeProblem - Oriented System (1973). Both describe the perceptions of a phy-sician of the effect of the use of the problem-oriented record on "hit"nurses in a coronary care setting. "The physician is now able toevaluate the performance of the nurse and identify areas that need im-provement" (Applying the Problem-Oriented_System, p. 384). Gardner(1972) stated that it is "of utmost importance that problems be listedtogether as soon as an association between them is established. Theerror of failing to recognize the relationalp between problems is justas serious as failing to recognize a problem at all" (p. 658).
Ob-Syn, pediatrics, school health, and college health.--Applicationsof the problem-oriented record and/or system to Ob-Gyn, pediatrics,school health, and college health programs are few. Narang (1973) con-ducted a study in a pediatric setting. A far greater number of problemswere identified by using the problem-oriented system, compared with thenumber of diagnoals established by using the traditional systim. The
. 49-42-
problems identified were primarily in the areas of malnutrition andanemia, and it is impossible to identify-whether or not the identifi-cation of these problems vas due to, the problem-oriented system or to'some other factor (such as the emphasis of a profesior)..
-Other medical specialty areas.--Applications of the problem-- oriented record to other medical specialty areas lave little relevance
for nursing. Applications of the problem-oriented record to long-terminstitutional care (Crawford 1973), cancer care (O'Connor 1974), pathol-ogy, and other medical specialty areas are included within the literature.
1 Dentistry, Pharmacology, nutrition, and other nonmedicai areas.--Applications orthe problem-oriented record in dentistry, pharmacology,nutrition, d other nonxcedical arias are also included within theli
laterature. ,
Studies and Surveys_ Regarding the Problem-OrientedMedical Record
Aranda's study1974) compared source-oriented and problem-oriented- records in a community military hospital with regard to the .number ofproblems identilied, the availability of objective-data, and the adequacyof Sollawuk sore problems were identifiediin the problem-orientedcharts (3.O'hctive problems per patient) ttiran in the source-orientedcharts (3.2 active problems per patient). - . -
Adequate data to support the diagnosis were found in a greater per-cent of the problem- oriented charts (for/72 percent of the problems) than
wthe source- oriented charts (for 69 percent of the problems). Followupas judged to be adequate for 85 percent of the prOblems in the'problem-
oriented group and for 77 percent?of the problems in the source-orientedgroup of records.. These differences wei-e not significant at the 0.001 .
level." The rationale for choosifig this extreme level of significancewas not given.
Additional findings oiedirdIfiling of reports in very -few (1.31.percent) of the problem-oriented re.---"Hs and in a high percentage (43.percent) of the source-oriented records. Unnecessary tests were orderedin 33 percent of the nonproblem-oriented cases. This vas probably dueto the inability to determine whether the tests hkd beenord4red or tothe loss of test results. The time required to onvert and to reviewthese records "vas also reported.
-
The author concluded Oat: 7Our results seem to demonstrate thatin a community military hospitalliadequate objective data andfollowupdoes not depend on record style and organization but on the quality ofthee7!setyations Made and the interest and time devoted by the primary
4.1 A
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C.
physician inotheAnteY4retation and recqrding of his clinical observe-,
"tions7.(p. 551). However, the problem oriented record did facilitatethe functiOns of tie records committee. It 'also decreased filing timeand improved the'filing system of the record room.
ti
Asp and hear's report (1973) of the -initiation of ,the problem-oriented sy em in Atommtmity hospital includes the results of threeinvestigations-.
1. 'An audit o' nonproblem-oriented records showedthem to belargely-Unacceptable.
2. An audit of problem-orient4Tecords shoved both a higherinitial quality df the regard and an improvement Over time.
3. A "subjective audit". of physidians' and nurses' impressipnsof the value of the POMR was conducted by means of a ques-tionnaire wh.Sph was distributed on two occasions, 4 monthsapart. The results_showed those physicians who responded tothe questionnaire to be_generally more faVorable to the POMRthah the nurses vho responded (36 of 40 for physicians, 32 of°140 for.nurses).
The favorability of nurses' responses decreased during the 4-month interval with regard to- the usefulness of the record and its-value in improving communication between 41 involved in the care ofthe patient. It increased, however, froM 58 percent responding-77es"t6 the qUestion "Do you feel your'pstient care has imprtOyed?" to 50percent. This article is notable forthe practical-Methods used tointroduce the system'and for the questions asked with regard to theeffects of the problem-oriented systL. The criteria for chart reviewfor both traditional and problem- oriented records are included. Thereporting of both methods and findings lacks consistency, but makes nopretense to.sophistication of research methods.
Campbell and Cooper (1973) conducted a survey of physicians in the, Department of Urology at Kaiser FOUndatIOn Hospital in Los Angeles.
The findings indicated that the_physicians:
1. Considered the POR to be helpful;
2. ,Thought that discharge summaries were easier to write;
3. Felt that the POR yielded better data.
Dixon (1973) reported the, results of an investigation of the numberof suggestions made by residents in their audit of interns' problem-`O-riented records and the interns' evaluations.bf:the usefulness of thesystem. The most favorable responses were related to gaining new ideas
4
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for plans from the auditor.' The least favorable were replieb to the
auditor's slIggestions of inaccurate information in the data base.
Fletcher's (1974r study vas designed to compare problemorientedand nonproblem-oriented records with respect to auditability. Nosignificant difference- was found betren the two types of records withregard to dependent variables of speed, accuracy, and numiter of errorsdetected on audit: In this tightly designed study, four complex medicalrecords were converted to'problem-oriented and nonproblem-oriented fof=mats and presented to 36 house staff members. An example of the initialassessment and plans for both formats is included within the.body oftke article. Both tormats-are typed and legible. The author's inten- .
tion of controlling 7ariabled not directly attributable to the FOR(such as legibility) is clearly stated.
Neq_on's critique (1974) of Fletcher's study was directed primarilyat the unreal form of the experimental model.in-which the sonrceToriented record was both well organized and legible. This, he stated,does not reflect the reality of clinical practice. However; he did-statcthat Fletcher clearly demonstrated that'when each format contain-ed equal amounts of information, there was no difference in the abilityorained observes to read and comprehend this information regardlessof rmat. Content,-not fort, determines whether the record can beaudited. Neelon argued tbat tae FOR by its very_ structure leads toAis-crbline in collecting and recording-information, whereas the source-oriented record does not.
?`room (1973) con4cted 300 patient records to the problem-orientedsystem over a 3-month, period, A mean of 6.4 minutes and a median of 5minutes were required to convert each chart at the time of the patient'stfsit. The author projects that an entire practice could be convertedto the problem-oriented system in this manner over a period of 2 years.
Gledhill's discussion (1973) of the addition to the record oreproblem-oriented medical synopsis is followed by a report of the'numberof problems identified before the use of this synopsis and afterward.Averages of 3.2 problems per patient vere.identified in the 907 'hartsreviewed for the "before" measure. An average of 4.5 problems perpatient (N=290) were identified for the'charts of patients/receivingcare after the introduction of thepynopsis. This different/ wasfound to be statistically significant, using log transformations of thedata. An additional investigation reported eight physicians' responsesto a questionnaire:
:Ma
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9.
Advantages
8
8865
1
Disadvantages
3111
0
Helps with case vorkup---Helps doctors communicateResearch
Extra paperwork.TimevastingInflexible format.potential.
Helps educate doctors--_Helps with patient care--
Leads to unjust criticismRedundancy of effort=----
The padvent
-responses to Gledhill's synopsis indicate that the
outweigh its disadvsttages.
Iverson and Yarnell (1972) surveyed general practitioners in theState of Washington. They found that only 23 percent of these-physi-clans were f; ar with the POMR and only 4 percent used it. About34 percent responded to the survey letter (1,203 letters, 407 respon,-ees), but a sampling of 100 nonrespondents produced no significantlydifferent results.
Margolis, Sheehan, and Stickley (1973) reported their investiga-tion in Applying the Problem-Oriented System.' The study was intendedto "measure the objectivity, validity, and reliability" of a gradedPOR as an instrument that vou/d evaluate clinical performance. At thesame time, an attempt vas made to measure the difference in studentperformance between those students who had a teaching resident -41assigned to them and those who did not. The "validity of the - gradedproblem-oriented record (GPOR) was established by having seven facultymembers grade a single vorkup. The checklist for grading the modifiedproblem-oriented record is presented in the article and consists ofvery basic items regarding content (presenting symptom, age, sex,numbering of problems) along with one more sophisticated item, "the.problem is currently. defined."
A .cofirparison of the midexperience scores for students with asassigned teachilg resident and without one showed a significantlyhigher score for students with a teaching resident assigned. However,there was no significant difference nor this group of students at thebeginning, middle, or end of their experience,.so whether these resultscan be attributed to the presence of the teaching resident is doubtful.These students were the Omogroup that had had the prior experience ofgrading a POR prior to the initiation of-the study. It was concludedthat the graded POR could objectively measure facility at data collec-tion and recording, as well as ptoblelm solving, and 'that st3idents weretaught these skills by grading a medical vorkup themselves.
Harang and others (1973) conducted a iieliminary study to identifythe number of diagnoses (or .problems) listed before the introductionof a modified problem-oriented system and afterward. The results showeda most impressive difference in the number of problems (primarily re-lated to malqutrition, anemia, etc.) identified: 140 cases were re-viewed for each period; 192 face sheet diagnoses were found and 454 missed
4
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4
during the first period; 490 face sheet "diagnoses were found and 12missed during the second period. The authors stated that there wereno differenced inthe number of house staff or in their workloadsduring the two periods. .They did not state 'whether or not there wps
any increased teaching emphasis or reinforcement with regard to iden-tification te, the problem-related to malnutrition during the secondperiod.
J./Nevble (1974), using a sample-of 10 physicians, -stuaied,their`
acceptance of Problem-oriented medical records. He'foun sgenerallyfavorable reaction to the parameters' chosen (practicality, importance,benefit to me, benefit to the patient, technicality), ana-the onlyclearly unfavorable reaction was to a final item the amount 0,1. timerequired. Scott andSniderman's study (1973) of clinical competence,rather than of the problem-oriented record, used a checklist based onthe problem-oriented format to evaluate the clinical competence ofhouse stafOmembers.
,t4
Seitz (1973) studied the value of the problem-oriented record infacilitating the,identification, treatment, and resolution of patientproblems. The Length of time required to identify, treat, and resolvethe problem of an-la before the introduction of the problem-orientedmedicd1 record and afterward was used as the criterion. The amount ofinformation relevant to anemia was also audited. No significantdi'ference vas found in either the amount of time required for any ofthese activities or in the amount of information relevant'*.o the prob-.1em before the introduct on of the POMR and afterward.
Hogan's report (197 of a survey of medical record librarians in18 hospitals using the POMP provided little information about themethodology she used. The results were reported. in narrative form only.They indicated that:
1. Original interest for implementing the POMR usually came froma physician.
//';2. Involvemept of, the medical records librarians .in initialplapning varied greatly.,
11W
'3. Anticipated difficulties in implementing,the system includedphysiciiiresistance, apathy, use of paramedical personnel forhistory taking, and lack of followthrough. These problemsvere less difficult than anticipated.
i
4. Coding of social, and economic problems-constituted a difficulty.
\\\4-5. Abstracting records vas easier.
6. Frequency of audit procedures,;mried, but most often was aboutonce a week.
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7. A great deal of time was require for teaching and followup.
The respondents stressed tea' involvement of medical recofd librarians,anticipation of problem areas, training all those who will use,thesystem, and followup on areas of difficulty-are important to successin implementing the POMR.
40(
Modifications. of the Problem- Oriented Record.
O
4
cMany modifications orthe problem-oriented record have been report-ed in the literature. Mazur .( "The Vital Balance Approach the Problem- ,Oriented Practice'," 1974) introduced a list of assets and resources onthe psyChiatric record. St. John spd Soulary (1973) initiated the useof go sd rather than problems, as zing elements for the record.May rentwood, Veterans Administr,lital, 1976) also developedand ntained a'nevsletter design d.t eminate.information regardingboth the use and the innovations i' use of the POMB.("Developments infrob em-Oriented Medical,Records,° anuary'1974). 6'
/'
t4t,uk-
Tag,-
Manuals and Teaching Guides for t of the Problem - OrientedRecord and/o stem
140
Many manuals hOe been de eloped for the usd of.the,POMR in specificsettings. They. consist F'*1 of condensations-of,POMR principlesand forms developed for secifid-settings. The Systeilddics Corporationprihts both the FROM II adult medical h4story questionnaire and otherforms for use in the problem- oriented medical practice.
C. NURSING AND THE PROBLEM-ORIENTED RECORD
4
igtroduction
The problem-oriented record and the roblem-oriented sygtem havebeen adopted by nurses for a variety of p oses and in a verietY ofsettings. The,problem=oriented'system, closely akin to the nursingprocesi system, -.encourages interdisciplinary collaboration which is, in
-.theory, satient center d. It is important, however, to differentiate
'*\ btween_the types of atient probleks which nurses menage and the types. 'Of patient problems w ch physicians manage.
4.
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I
-CoAceptp, Philosophy, ant, Dcscriptiont of the Use of theProblem-Oriented Record-and/or Systemlby Mimes
Books and Monographs
The National League for Pursing (1974)0published a book, TheProblem-Oriented System --A MultklisciplinAry Approach, in 1974.. The
pages of thid book pro'.de a lear, concise, graphiC descriptionof the problem-Oriented record: its uses, 'content:advantage, anddisadvantaaes. Several exercises designed fOr groups follow the seriesof articles which constitute the bulk of the book. Lambert's articlein this bobk 54 specifically related to the general princip4is of the'problem- oriented system'es it relates to nursing and is included sepa-\rately below. 0
Woolley, Warnick, Kane, and Dyer's concise book (1974) is an intro-duc ttthe prObiem-oriented system (resigned for nurges. It includesa eral description of the system and chapters on audit,'educatioimilementation, and experience :rich the Trobjem-oriented sygtem.ceIlent graphic presentations are inclUded within the'text. The sectionon.proble= identification is presented from 4 primarily medical poiptof view. It.also includes a series of exercises, which although basedOn medical diagnoses, are excelleatfdr Understanding the'principlesand use or the kR. A "nursing" data base follows. _This includes a
. review of'systems and physical examination. Berni/and "Reaay's bc6k/-(1974) is directed to allied health personnel.
Walter, Pardee, and'Molbo's editegbPok, Dynamics pf Problem-
,
Oriented Approaches: Patient Cape and Documentation-11976), is anexcellent presentkion. This book includes three major- sections--"Concepts and Theories," "Implementation,"'and "Expansion." The.similarity between problem-oriented problem-soving techniques andnursing procese"approaches is described. Clients' prOblems in illnessand "wellness" and nursing diagnosis in the problem-oriefited systemare discussed in Section I, "Concepts And Theories."
Section II, "Implementation," includesichapters 6n "HolisticLmplementalionOP "Problem-Oriented Charting," and "Implementing theProblem-Or eated Process in Home Hewlth Car. and With Other D sciplines."
, Chapters oniactinicai Specialization," " e Expanded Role " a d "CpmputerApplication are 80.0 included. pection III,."Expansio , c iders"Integrationaof the Problem-Oriacqed Approach the Patient DQC .b41."tary System;" "Participative Health Care;rn "Integration of Problem-Oriented Approach With incepts of NuAing;", "LegalAricat(fon;" anda final chapter; "Tairard a Creative Professional Cl e for Nursing 1,/
..qPractic,e.
-Meldnlan, McFarland, andlohnson's boolc,.The Problpm-Oriented Ny-.chi&tric Index and Treatment pans (1976), is based on ;philosophy of
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a goaloriented approach to care for behavioral problems..'It includesindices of goals aId methods,.treatment plans, and progress notes. A,
tive-digit _code is provided for every goal and treatment method. Manyof the goals"defined have relevance for patient problems which are seenih both pub)* health"and general hospital settings.'
Articles
Atwood and Yarnall, in their preface to an issue of Nursing Clinicsof North America dedicated to the POR (June 1974), stated their inten-tion-of presenting an interdisciplinary approach to the use of the
- problemi-oriented record by nurses. It is diphasized that "there is.nosingle approach to the POR and that the system must be individualized
% to each particularipractiCe." ,
In a later article in the sane issue of this journal, Atwood,Mitchell, And Yarnell. (1974) raised questions regard'ng use of thpPOli in the "real world." The shift in emphasis from ver to writtenCommunication provided by POR is discussed. Physician- communica-tion is enhanced by the system, as "pkrsiCians become be ter acquaintedwith what nurses can and should. do. In so doing th become moreinvolved in teaching and assisting nurses to prat ce more effectively"
N(pp. 222-23). The problem-oriented record makes at each person isdoing.more explicit and thereby facilitates trust d decreases duplica-tion and confusion. Resistance to change is a kraman charlcteristicand gust be'anticipated when One considers implementation of theoriented record.
.
ckaptree (1974) described the probl riented system, provided acase -example of problem orientation, and liatea-the advantages of the
Two of the ten advantages liste differ from HUrst's "TensReasoniLsyrende Weed Is Right" (1971). These fnclude sifting data and
minimizing irreleyancies and documentation of the quality of patient4 care. Sheeautioned that the system is not:a cure-all and rewiresstaff education for implementation.' Nt
Cadmus (1973)' discussed nursing care plans and the POMR. She,stated that before the POLAR nursing care plans have primarily been onlyrodent exercises. They were recorded in kardexes-and considered dis-posable,taak oriented, and primarily illogical. The problem-orientedsystem is an instrume change. The initial care plan includes
'nursing measures for:
1. More data,s
2. Specific treatment,
3. -Patient edu;Catio.n.--_
re%
1 57)-50- '
a
Garde, in "Spark: A: Success Story" .(1973), provided a humorouspresentation -4f the Rrinciples and use.of the problem- oriented recordin .cartoons: In as article in The'Problem-Oriented Systel (1'972),Gane stated that understanding the reasons for physicians' orders is"made possible" by the use of the problem-oriented record. Nursingcare plans can be made in conjunction with the physicianls therapeuticplan. Problem orientation also hermits comprehensive care (awarenestof all problems). Atteition to specific problems fosters the patient'spercepti66 of being, cat'ed about. By recording on the same progresssheets, nursing_cantmake4a professional contribution that invites comementl action; criticism, and meaningful audit.
t
Gene's "Eorevord to the Sympositim on the Problem - Oriented Record"in Nursing ditties of North America- (197) states that the pioblem-oriented system is,a concept which it 15 years'old and is being unced...kymembers of many-AiNciplines.. The, problem-oriented system is a toolthatovill alloy us to accept the Challenge Of doing what we vebelieve in. * LM an article. in Applying the Problem-Oriented System,Gene (1973) described the value of the problem- oriented system fornursing. Knowledge of.ell the patients' problems changed the way thatthe nurses on ber unit practiced nursing. "Using the problem-orientedafproach makes it possible for the nurse to render coMprehensive care;
' to think of the patient an a person." The formulation of plans and theprogress notes are discussed. The benefits of problem-orientation andfuture implications are presented.
LembertOn a National League foryursing monograph (1974),*aescrib-ed the probleh-oriented system as a whole philosophy of patient care withdocumentation -of care, peeA audit, and correction of deficiencies asaspects of this systemT The implications of each of the componentsof the problem-oriented system are discussed. Defining a.data basereouires coordination of physicians' and nurses"efforts to avoiddutlicationin questioning the patient. The relevance of each ques-tion must be.considered in light of the willingness to act responsiblyon the basis of the answers obtained.', This foices a continuous ques-tioning and development of practice.
. "The problem list makes the need_Zor care ce all the'patienl's
problems obvious. The initial plan includes consideration of the plansfor; patient educatibn; the progress notes force the aocumentation ofnursing judgments. As a, result .cf this system '(the development of adata base and defining the parameters for the care of certain patientproblems), patient care at the Medical Center Hospital of Vermont hasimproved. All members of the health 'team communicate: and all areplanning for the patient'andwith him.
- Malloy (1976) questioned the' appropriateness of the problem-orientedrecord fOr.nwsing. 'She stated that it is "... . an approach to patientsfocused on their problems" and "is misleading-if the overall goal ofnursing is to assist a Person taVard optimum health. ",, "nib," she stated,
tc
-5E5-51-
"emphasizes disdbilities rather than an acc urate picture of bothstrengths (or resources) and weaknesses (or limitations)" (1). 582). Inaddition, "Nursing objectives are submerged to a subconscious, unstatedlevel" (p. 582) It would be more valuable to focus on the objectivesof care. "Important areas of patient care will be neglected if thesame problem list is used by both nurses and physicians. Nursing mustmaintain its contribution of health objectives developed with the personand his family and based on nursing assessment and priorities."
Mitchell (1973) mated that the conflct between the ideal (nurses'notes are'itportant) and the real (nurses write few meaningful notes)is resolved by the problem- oriented record. Nursing care data can beadapted to the problem-oriented for at. Examples, of nursing care datain-problem-oriented format are provided:. The-advantages _of the PORare discussed. These include improved patient care, increased profes-sional collaboration, permanent documentation of care,crffical think-ing, and benefits for teaching nursing students. The difficulties ofimplementing the problem-oriented record include visibility of.tbenurse's clinical thinking and the difficulty of using brief flow sheetsafter being accustomed to narrative notes. Different professionalviews in defining problelas can le /resolved by looking at prob frcathe patient's point of view.
Schell and Campbell (1972) stressed Weed's philosophy of theimportance of teaching a core ofVtehavior rather than the memory offacts. The components and advantages of the PCLMR are described.Logical, explicit description of the patient's problems; efficacy;,evaluating the team's performance; and immediate, meaningful feedbackfor education and audit constitute the advantages. The problem of _thethreat of exposure provided by the PCHR'is mentioned. The impact oneducation (the stress on behavior rather than memory), the value forresea'r'ch (logical, explicit data), and the 'common approach Of nursingand medicine necessary for "expanded roles" for nurses axe presented.The concepts and terminology diffei little from 2ther nonnursingpresentations of tie content and philosophy of the problem-orientedrecord.
Yarnell and Atwood (1974) stated that the problem-oriented systemputs the emphasis back on the patient_and his problems. Areas affectedby the problem-oriented appf6ach include the q.even C's" of: (1) care,(2) communication, i3)-scost, (4) control, (5) certification, (6) con-sent; and (7) confiaentiality. The components of the problem-orientedrecord are described.' The first rule of implementation is "start withyourself." .j} it, and indivi&R)ize the system to your own practice
setting:
5 9-52-
A
Initiating the Problem-Oriented Record and/or System
Methods of Initiating the Problem-Oriented Record and/or System
Matthis ("The PToblem-Oriented System in Publib Health Nursing,"1974), a consultant to the Visiting Nurse Association of Omaha, Nebraska,described'the'reactions of the staff to initiating the POR. Classicpatterns of denial, overt anger, quiet depression, and final acceptancewere seen. The problem-oriented record'is simply a new term for nursingprocess. The service goals of the agency should determine th2 data basecontent. The greatest part of the article refers to the steps in the .
nursing process. "PCMR GroupEttercises" (National League for Nursing,1974, pp. 67-86) consists of apsm-nAry of reports of brainstorMlhgapproaches to methods for introducting the PCHR in a combined publichealth and Vii organization. The content is not limited to a publichealth agency.
A comprehensive manual by the V tglLing Nurse Association of ,
Burlington, Vermont (1975), pr'vides concise, specific information.The sections of this manual include:
1. The problem- oriented record--its organizing principles andits structure,
2. Guidelines for training personnel in the use of)roblem-oriented records,
3. Curriculum outline for training,
4. Forms used in the problem-oriented record and instructionsfor use,
Semple records,
6. Reactions to the prOlem-oriented system,
7. Selected bibliography.
dun short, it includes everything which is necissary for establishing theuse of the problem-oriented record in a he health agency. Much ofthe content is relevant to the use ofthe problem-oriented record byprofessional nurses in anything qther than the most acute care settings.The third section of Game's .unpublished manual (1974).is entitled "Novto Practice" and presents the methodology for use. of the problem-oriented record fh nursing. All three unpublished manuscripts by Gene,
. "Handbook of Problem-Orientation for Nurses" (1972), "Nursing:. TheProblem- Oriented Way" (1970, and "Understanding tire Problem-OrientedRecord:'; A Book of Exercises" (1975), constitute valuable resources forimplPinenting the POKR,,especially in inpatient settingh.
60-53-
Reports of Initiating the Problem- Oriented Record and/or System
Abruzzese (1974) reported thesystem by the nursing staff at St.City. A major concern was to keepwithin the nursing rather than thethe problem - oriented at theDepartment of Nursing (Davis 1974
initiation of the-problem-orientedLuke's Hospital Center in Nev Yorknursing diagnosis and assessmentmedical realm Implementation of
ern Pennsylvania Hospital'sted in the following changes:
Nurse-physician relationships included greater acceptance ofthe nurse as a coprofessional by the physician.
2. Burse-patieTt relationships were deeper and more therapeutic.
.3. Professional function was miore effectivevith a well-definedframework.
4. The hospital was closer 'to the possibility of Computerizedrecords.
Both general and specific objectives for implementing the systemwere developed. General objectives included:
1. To credte trrealistic self- image of the professional nurse.
2. To create an intellectual egyironment where questionning andself-directed learning are positively reinforced.
3. To provide a clinical situation which offers students theopportunity for systematic clinical education.
sik
4. To create an environment in which the nursing teas is stimu-lated to develop thoughtful, scientific care.
Specific objectivesVors'related to documentation kg informatiolk. ThePOR's progress note _format (the "SOAP" note) was amended to provide aformat for recording interventions. A SOW rather than a SOAP struc:rtore vas, provided for the progress note. Employees responded favoraiikatc the system, and the authors believed that the problem- oriented systemof charting is the best method for dodumenting patient care.
The Ilblem-oriented system was initiated in & coMbined agerky asthe result of the frustrations of attempting to audit traditional records.(Kelly and McNutt 1974). A general assessment database was developed
283), and the opening summary vaeretained.4fcause it helps us tosee the family as people, not just as a group of problems." The SOAPformat was used for both he visits and phone contacts. ficultiestin.identifying format space for information which is re but not .
problem based (such as type of living arrangements) were noted, and thegeneralrule"ifyoucanusethe.informationinsonleway,Acludeit"
.
-54-
was adopted.,
"Kinney-and othdts (1974) a aluated the difficulties encountereiJr.-in' implementing the problemo nted record on one unit of a communityhosttal. They identified the following problems:-
1. n-sr
Problem lists were maintained by only a small percentage ofthe attending staff;
e
2. The inservice training of new nurses was a constant challenge;
3. The SOAP format-overwhelmed the:nursing staff;
4. The medical staff did not adopt the problem-oriented recordas an Vficial part of the chart (pp. 249-50).
A nursfng coordinator for the problem-oriented record was appointed to.work with the Directdr of Medical Education. Ploy sheets for nursingparameters (care, activity, food, mutation) were designed, apparentlyto cover nursing problems not included in medical problem lists andnonproblen-based nursing functions related to the maintenance ofpatient's normal functioning.
Payne, McBarion, and O'Connor (1974) reported the difficultiesand accdhplishments in implementing the problem-oriented record in Rcoronary care unit. Nurses began charting progress notes in problemareas defined by body systems., The authors stated that this was foundto be a useful educational experience for the uarses and an effectivestrategy for implementing structured notes. Both general- purpose andstructured,.pliblem-related flow sheets were designed.
.An'editor of Registered Nurse (Rh) magazine described her visitto the Medical Center Hospital of Vermont to observe the problem-7oriented. medical recole in use (Robinson 1975). The information,reported serves as a summary of the original publications of Cadmms--,Gene, Milhous, and Lambert. Information not in other sources includes,the following listof "Don'ts" for implementing the system. Do not:
Ram the syst down eveiyonels throat.
hefStart w re resistance is strong.
Start with the data base and/or progress .notes. Do startwith the probleat.
Wait for physicians to come around to the system.
Do it unless you have a supporter o.is on the unit.
Ignore adninistrative leaders. Da include them from thebeginning.
62
-55-
.01
Forget to invite everybody to inservice meetings about the POR.
and Pittman (1972) reported the initiation of the'problem-orient d system for recording nursing care in an extenaed-care facility:,The as essment, planning, implementation, and evaluation of nursingcar s discussed, and the findings of a chart review 3 weeks after
initiation of the system is presented (see the followi s).Thompson's report of the process of. initiating the problem- orientedsystem in a home health agency is described in Applying the'Problem-Oriented System. The final report of this project, which was in pro-cess at that time at the Visiting Rurse Association, Inc., Burlington,Vermont, was later published as The Problem-Oriented System in a HeHealth Agency--A .Training Manual (1975).
-- Woody and Mallison (1973) presented an extensive description of .
problem-oriented system and its-components and described the changeto the problem-oriented system by nursing at Grady Memorial and EmoryUniversity hospitals. A gradual approach to adoption of the systemby different units was used, beginning with the coronary care unit(see Silverman 1972 and 1973). Collaboration between medicine andnursing was required to develop the data base. Frequent, auditing pro -vi d feedback to the users of the system. At first, "general" wased to designate proglens of hygiene and activity, but was later dis-
continued. Separate nurse's notes were discontinued and incorporatedinto the physician's progress notes. Anxiet a writing "assessments"occurred. Kardex care plans were conve ed to problem lists on thehemodialysii units: ?-Constant revision of forms was reqtired during theearly stagesof development.
.Applications of thp Problem-Oriented Record and/or System
Nurses have applied the'problEm-oriented. record or problem-orientedsystem in audit and education as4vil1 as in a variety of settings.
Functions
Audit. Mention of the value Wthe problem-- oriented record foraudit accountability, or peer revyey is made in most nursing articlesre ding the problem-oriented syeitem. These have been reviewed84,t9taing to their major =tear.' Asp and Brashear's ().973) interdis-'ciplinary approach to audit is reported in the "Studies" section of
"fiis bibliography.- In essence, the quality of nonproblem-oriented"records was largely unacceptable., Both a higher initial qnAmity andimprovement of records over time were identified for problem- orientedrecords.
r
Bonkovsky 11972) initiated a Yogram of,peer review Imonthsafter the nurses in an outreach program which. used the POR. Eachnurse evaluated 10 records of another nurse with regird to:,
..
Weitification of all health problems;
. Presence of a plan of care for each problem;
Clarity of the description of the current status of all patients.
Gene ("Nursing, The Problem-Oriented Way," 1971+) described performanceaudit. She stated that it is directed to the consideration of Weed'dlis a four behavioral traits: (1) thoroughness, (2) reliability, (3)
is sense, and (4) efficiency. Each of these traits is.defined.an
-keen:As from Sphell wad Campbell ("POMR, Not( Just Another Way To Chart,".1972) with regard to the value and the threatWeed's "On Being Responsible and Setting Prioin its entirety. The Medical Center Hospital bf Vermont's "Standardsfor Patient Care and Peer Review" and methods for review are also included.
6Education, continuing education.--Hawken (1973) stated that nursing
educators can contribute to the problem-oriented approach in the areasof collaboration, educative process, value orientation, refinement ofthe process, and sharing ideas. She also stated her belief in a commondata base for nursing and medi,pine. Different data bases, she felt,would divide the patient. Nursing' educators can assist students .indeveloping the cognitive process necessary to use a problem-solvingapproach. Emotional aspects.of patients are not evident in the-existingguides for nursing assessment. Nurses.need to consider what the infor-mation megns to the patient.
The Emory School of Nursing h ollaborated with the National Medi-cal Audiovisual Center in produci ilm, "Implementation of theProblem-Oriented System by the linician" (free distribution) whichincludes segm4nts on (1) a systems approach to family functions, (2);hysical assessment, mad (3) continuation of the problem- oriented process.Mitchell and,Atvood (1975) studied the "critical thinking" of beginningnursing studenti vio were taught problem-oriented charting as opposed tothose who were not so taught. They identified no differences in thenumber of patient problems identified on a paper-and-pencirtest. Hoy-ever, the problem-oriented group did identify more problems in a clinicalsetting. This study is reviewed in the "Studies" section regarding theuse of the problem-oriented record by/for nursing.
of Ruflit is iticluded.,
Mies" (1973) is presented
Role of the Problem-Oriented Record and/or System inPromotingInterdisciplinary Communication
.4414
Much of the ,literature
,
f
regarding the uses? the problem-oriented
64.
V-5 7 -
If
Atrecord by nurses or in nursing care settings is related to the valueof this /record system for achieving interdistiplinary communication.Two basic compilations of articles, the June 197; Idsue of NursingClinics of North America and the liational League for 'Nursing's TheProblem-Oriented System--A Multidisciplinary Approach (1974) de'with the value of the problem- oriented system for interdisciplicollaboration.
Many of the a rticles included in these two sources are presentedunder the specific settings in which the use of the problem-orientedrecord is_described. Almost all articles about these of the problem-oriented record in nursing care settings mention its value for inter-disciplinary communication and are reviewed according to their primarytopics. Those articles which relate specificAlly to the use of thePOR for interdisciplinary commlnication are included in the foliatingarticles. Atwood and Yarnell's Dreface (1974) to the Nursing C1&nicsof North America stressed the importance of int sciplinary collabo-ration in implementing a problem-or Lented record . Each of the'articles included represents an interdisctplina- ;ort. All but onearticle were coauthored by a nurse and a sician.
Lambert ("The Problem-Oriented.System as an Aid to Lmpl'oved .
1974) Stated'that one of the greatest benefits of the problem-orientedsystem is improved collaborative planning, Nurses have never aggressivelytried to demonstrate to others, what the nursing content of patient careincludes. The author's plan for a specific routine for home care wasplanned with the patient and charted in the clinical progress record.It resulted in responses from both the house staff_and-the,ittendingphysicianst A weekly discharge planni onference evolved. The medi-cal records department gave permission for es to write in the prog-ress notes, and respeet and undaratanang bete yaici and nursesgrew. Training sessions in problem-orientation were tab ished forall. disciplines that provided care for the patient.
The-process of developmerft of a hbspital-wide data base led toAifferentiation of content and consequently of roles f various dis-ciplines. Problem identification and recording remained the-respon-sibility of the physician, but a temporary- problem list was used bymopes. These problems were evaluated for inclusion on the permanentproblem list: Sharing vtitten comments on the patient's behalf re-Suited in more consistent medical follovup than the previous verbaldiscussions achieved. -
ThompsOn ("The Problem-Oriented System in Rope Health Agencies,41914) stated that the POR's requirement that all information is re-7,corded in common locations of the record results in clearer communica-tion of the roles and responsibilities of each team member. Combiningagency records with community physicians has made patient informationmore accessible and the .contributions of the nurse more evident:Patients also have more information about their health needs, problems,^and care, and as a result can make some judgments about the quality of
ty
65
care which they receive. Rtraluation of care is facilitated both doan individual patient basis and for utilization review because of thestructured, explicit nature of the record.
.
Settings and'Servides
Publtzhealth.-&-Applications 'of the record or record system topublic health settings or services have been reported by several authorp.Aradine and Cuthneck (1974) reported the use-of the problem - orientedrecord in a family health service. Mechanisms. for incorporating theproblem-oriented record into a child development and family healthcare setting are described. The pediatric data base (including thescores of Denver Developmental testsris considered to be "additive."Health assessment, supervision, and promotion are the first problem forall patients. Differentiation between nursing problems (those vhichare managed by nurses) and npathophysiological problems" is approachedlogically Weed's definition of a problem, "anything that requiresmanagement," serves as the basis for this distinction. Management of amedical problem may constitute an additional nursing problem.
Flow sheets have been devised for health superviaion of childrenfrom birth to 2 years. Forms are considered a too1445rather than arigid format, and are,ped in combination Vith interviewing skills. Anoverall plan incorpoites items for all problems and is recorded incomplex situations. The authors stated that "the'system . . . needsfUrther development in the areas of health education and in recordingpatient and family goals, strengths, assets, and abilities as well asthe problems they Present" (p. 1112). They concluded, however, thatpatient care has been improved and continuity 'of care strengthened bythe use of the problem-oriented record.
Eonkovsky (1972) descrged the use ac the POE, by nurses in threesatellite clinics of Children's Hospital tn Washington, D.C. A data basevas defined and Problem 1 of the problem list vas always "well child" or"routine health supervision." Three months after the problem-orientedsystem was initiated, peer review of records was begun. Some stiff mem-bers other than nurses began to use the system as well. The advantages .
of the system included inereased.comprehension of the patients and theircomplex problems, increased stimulation and professidnal satisfaction,and better continuity of care with transferred caseloads.
Field (1971)_stated that physician, nurse, and patient are separated'by innumerable barriers to.eommunication. A community health coordinatorbased in a hospital (Dartmouth-Hitchcock Medical Center) suggested theuse of the POR format to a few community nurses. Community nurses vere*invited to participate at a problem-oriented workshop in the hospital.The problem- oriented record improved communication between nurses andPhysicians and thereby improved patient care.
.
Matthis' article (1974) dealing with initiating he POR and Kelly
O
and McNutt's article (1914) dealing with implementing the POR are both-applications to public health agencies. However, each is consideredelsewhere in this review. Thompson (in Hurst and Walker 1973), statedthat the semi - isolation of a home health agency facilitates the initia-tion of the system by airlinishing the problems of redtape and by ob-taining a consensus of a.mixed group orlirofeSsionals. Problem-iorientedreports to physicians res147:Ced in their increased awareness of the roleof the ilublichealth nurse in relationship totheir patients. Third-Dartrpelyerseven tollnd a change in forms acceptable.
Laura Weed served as consultant in the changeover to problem.-- .
oriented records. Records were developed, field tested for 6 weeks,revised, and tested again. The'conversion was relatively painless, andstaff acceptance was great.. -The components of the problem-oriented ree-
, ord and the forms used for each are presented with a case example.Audit is-perfor=ed more easily with the problem-oFdInted record. Ini-tiation of the system was an exci'ting endeavor, and the author stated: 4,9
offers nursing an opportunity to-define its practice and to com-municate with other professionals in a sophisticated, logical, and vex"),re-tient-centered way."
In her article "The Problem-Orientep. System in Home Heal;.a-Agencies,"'Thomcson stated that the problem-oriented system is so logieil and sopractical that one wonders why it did not originate earl. Althoughnursing process and other approaches were similar, the-were not usefulto Other disciplines and health care providers. A t from theDepartment of Health, Education, and Welfare faci14-ated the initiationof the system for this agency. A pilot group of taff was formed, andDr. Laura Weed served as consultant. Record forms were studied, estab-lished, tested, revised, and a fi.nal form wasiestablished. Flow sheetsfor diabetes mellitus, cardiac disease, arid antepartum care are included.
In the ..kr, article in,the same monomph, Thompson (1974) describedthe program n which the Visiting Nurse kssociation of Burlington, Vermont,began to c ..:tine records with community physici s. Problem- orientedreferrals now come from e variety of sources an yield a more completepicture of the patient. Both coordination of planning and evaluatic ofpatient care have been improved. The Visiting Nurse Association ofBurlington, Vermont (1975), pt lished a training manual as a result of aDivision of Nursing,.:etartment.of Health, Education, and. Welfare, great.This comprehensive source of information regarding the initiation ofthe -
problem- oriented system in a home health agency is reviewed under "Methodsfor Implementing the system."
Ambulatory c are settings.--Applications of the problem-orientedrecord and/or system in embulatorf care settings have been desefibed byBrydon (1973); Taylor (1973); andLeonard, Coward, and Mattingly (1974),Leonard and others (1974) included a health maintenance flow sheet frombirth to 12 months. This flow sleet Includes criteria for both thechild's development and family behavior.
6-60-
agehgbilitation settings.--Application ofthe problem-orientedrd and/or system in rehabilitation settings have been described
and reported by several authors. Bermi and Nicholson (1974) describedthe use of the problem oriented record for patient care and teaching ina rehabilitation 'program. A flow sheet for bowel training is included.Conti (1975) used the problem-oriented record
atthe basis for her
annual report for the Department of Nursing at the Maryland Rehabilita-tion Center. The numb6yeand percent of patient problems resolved by iv
'nursing were usea-tb d6cvment the success of nursing care.
Psychiatric settings.--Applications of the problem-oriented recordand/or system in psychiatric settings have been described by severalnurses. 'Gerken, Molitar, and Reardon (1974) presented the methods anddifficulties of the transition from a source-oriented to a problem-.oriented system in three State hospitals. They found conversion ofrecords ofklong-stay patieits to be very timeconsuming, but valuablein uncovering problems that had'been 'neglected. Behavioral observa-tions, rather than physiological parameters, provided the basis.forassessment.t, The ?OR provided a more unified approach by the treatmentteam. A nrdblem classification guide and sample problem list treatmentguide-are provided. Hawley, Smith, and Grant in Walker, Hurst, andWoody 1973) described the audit process as applied to psychosocial care.Huff (in Walker, Hurst, and Woody 1973) piesented a data base developedfor use in a psychiatric inpatient service at Grady Memorial Hospital,Atlanta, Georgia.
general hospital settings.--Nqrsing applications of the problem-oriented record and/or system in general hospital settings weredescribed by Sane and others. Chapter 6 of (lane's mimeographed manual
at
(1974) includes sampr} records from medical-surgical, rehabilitation,coronary care,,ob etrical units, and the emergedcy roam. Cadmus(1972) described her experiences with the problem-oriented record onthe gynecology unit at tne Medical Center Hospital of Vermont as "asystem that truly places the patient at the center; Nov we are ableto see a person with problems and in turn, we strive to establish our-selves as persons working to solve them." Kinney,cmith, and Barnes(1974) inclu&d a flow sheet,for activities of daily living in theirarticle on the use of the FOS-on a medical unit of a general-hospital.
Acute care and coronary care settings.--Applications of theroblem-oriented record in acute and coronary care settings have been
Presented by Payne, McBarAn, and O'Connor (1974) and Silverman inboth The Problem-Oriented System (1b972) and in Applying the Problem-Oriented System (1973).
138--61-
,
udies Regarding.theiJae of the Proble -Oriented Regord. .,
.
-, .
and/or System
Asp and'Brdshear (1973) surveyed physicians and nurses' responsesto the initidtioh of the'problem-orientedisystem. The survey was con -&acted twice during Octbber 1'72 and-February 1973. Thirt)h.two offorty nurses fesponded during the first survey and r36 of 40 during thesecond survey7,The questions and the n7r:es' responses, during thetwo.surveys are presented as follows:
...
.
,
. 1. 'li the.PQMR clanged your responsethe
., ,
'- R esponseesponse "-yess
Octk Feb.Percent
55
, 50.
.
Y2
56P
_,
18
38.
---,--
§'
75
atient?2. DokxouAb 'eve tat your care oil ,
patients h ipproved?------ -- -
3. ,Do you feel the chart-is moreuse-.ful tqcyou? , --
ria?-- ---PDMii-improggrfo,.._-- -fir-
between all involved in the care of.your patient?
Allies the POMR increase-your time in-\rooted in patient management? ---- *19-. 39
Questions 5 and' 6 were-answered b'yf physicians only and refer_ to con-sultatiqn and length of stay. :
/..
The nurses, although responding Worably, *were less positivethan the physiclant (14 of 20 M.D.'s responded on 'bdth. oecasionp)...More nurses responded "yes" to QueStioni 1, 2, and 7 during, the secondsurvey'than during the first. 'Less responded favorably to Questions 3and 4.afteOthe time lapse. However, -it was to tSse'tvo questions,"iiaprovement ofpiLtient care" and'"utili f the cha/t" that moreAl
nurses responded lavdiablY...,.
,
: . mBertucci,.Huston, and Perloff-(1974) compar-. 'pfoblem-oriented
and traditional methodkot_:charting. A.sample 15 subjects was takenficki each Of 2 groups of registered nurses. Os- grpup had previously
A been taught the Weed syitemi'the other had ot. Ptoth-groups were askedto respond t9 five paper-; a ' IP c patiet care' situations by writing
. hurse's notes as' if they Aad been as,--- 4,--.the care of the patient.Criteria for evaluatib 6f the information recorded consisted of eachof the compodenta.of SOIAPnote. A score pf "l's was given for eachcriterioeincluded. Not surprisingly, the group who had been taughtthe Weed syptem included a higher number of its components 1,4 their,recording than those who had not4beentaught it. Many participants inboth groups id 'not record assessment and direct nursing intervention.Four participantsoin group 1 and none in group 2 held baccalaureate'degrees.' ,
, .
Bloom (1971) iodentified the value 'of the problem- oriented systemfor organizing information, thoUghtful practice, airareass of thepatient's problems, and awareness of relationships between IM)blems.Freedom for independent nursing judgments and improfed relationshipsbetveeL disciolines are' among the values of the system. The last pageof this article desEribes agilot study of record style and contentand an evaluation of patient care on the physical medicine.unit. Pa-tient care was improved, and the nig* chart content facilitated continu-'ity 'of care between shifts and over .:er periods of time. No numeri7oal results were reported.
Foss an 11's ,pilot study 41974) of ,the effects of the probleb-oriented reCpr. o the f
iecordingof Patient care tctivitles was con-'ducted in'tvo phases during the initiation of' the system in the hospital'spursing service. .In phase I, workshops were conducted on seledted units ..
to prepare for theuse of the POMR by nursing The audit of 24 randomly 4Selected chants (12"from traditional and la from problem-oriented charti).showed great improvement In the problem-oriented charts, compared withthe traditional notes. Evidence'of a beginning'nursih care lan list-.1Irg-mare-soterfic nursing interventions,_and inc/usion_Of the patientf_s-emotiona-I reactions to illness and to care appeared more frequently inthe problem-oriented records. A questlapnaite was distributed tp thenurses,'aad the ma,joelty stated that they preferred the lirobleM=orientedsystem and that it made them think more about documenting nursing assess-ment before beginning care. They did feel that the POMR was more timecon-suming and that it needed modifications.
4. . . .
Phase II was cohdUctedto comparethe traditional PONE format withthe modified form (the "S" and Ple,:of ttic:OAP note were dropped, and
werethese responses we included within the sesiment). e:audit of 11POMR and 13 Modified POMR charts showed only slight imf4ovtment in. themodified POMR, compared with the traditional POMB..format,,m A questionnairefound that the nurses felt that the system was mare timeconsuming only--
in the initial stages of use. More than half gated that there was nodifference in patient care due to th'e modified PJ MR. Mantle and others(1973) analyzed nursing flow sheets in an acute care unit. The noteswere compared with a "problem-oriented theoretical standard." The con-tent of the recorded notes was found to be significantly below the stan-dard. . A
^
Mitchell ana Atvood's-study (1975) was desigeed to test problemidentification; documentation of plans,,actions, and'evaluations; andquality of the organization of recordstin students who had.been taught._the problem-oriented system, CompakedWith those who has not. Sophomortein a baccalaureate program in nursing were divided into 2 groups of 73
sThe study, group was taught the problem-orientea format; the controlgroup was nqt., p5istructors for both groups stressed the inclusion of thepatient's subjec,tive responses; nurses' obseVations; inferences baSed.ondata; and plaza, actions, and evaluation as the ideal content of the red-
s ord. It was also stressed that both groups should complete informftibnregarding one 'subject before beginning another topic. .
. -63-
Three samples of the student's clinical charting were ebtained.athe 2d, 6th, and 9th weeks of the school term. Apaper-and-pendil t6stof a written case history was given on the 9th we The bypothV.es.stated that.the experimental (problem-oriented record), group woula dobetter than the control group with regard to problem identificationAnd documentaAen-of problems. None of the hypotheses were supportedfor case history ("paper-and-pencil") material. Mixed findings werereported for'the clinical recording of the two groups. More problems
'were identified and the documentation of plans, actioas, and evaluation'was sigaificantly greater for the group of students who had been taught 4
the ..problem- oriented method.
Mooney .(197'2) compared'aroblem-oriented:and nonproblem-orientedaurielp notes. She found that bath the adminie-t-mtionof prn medications .hnd tee patient's responses to the medication were recorded signifiCantlymore often in the problem- oriented than in the nonproblem- oriented nuilsingnotes. Thome and Pittman (1972) tested the concept that th44Content ofthe record form reflectaythe expectations' of the fqrm. An audit was corii-ductPa after thP -crit ri a fay Pulit _and_the---f-indlegs were
IN
1. 'Nursing problems had been identified .and listed on. the appropriateform. All patients, bad five or more problems-identified.
2. 'a, -Nursingcare plan's were preseht for each problem. .
b. Nursing care plans' were consistent with nursingrassessmentl,. it was found that planswere less likely to be recordedif th problem was added after the forms for the patient hadbeen tarted.
3. 4nartiniof care was related to the nursing problem.Charting of card included an evaluation of how the care planwas working.
The authors stated that charting nusing'oare reflectedthe nursingCare plan for the patient. If the care was consistent with the plan, nospecific charting was required. Rather, evaluation of-the patient's
' problem was recorded. The flow sheet for recording dependent nursing'functions was difficult to use, and the-nurses felt that it did net pro-vide adequate legal piotection. It was dropped, and the previous formswere retained. ',No numerical findings were presented. The author con-cluded'that problem-oriented charting has been useful in documenting thelevel of'skilled care in the extended-care facility.
Sivett and Good (1973) established a progrilm of continuing educationfor nurses' in ordersto develop the nurse's three roles: data collector,decisionmaker, and teacher of patcents. Four nursing stations wereselected on vbich to implement the program.. The nurses on each unit wereinstructed in the use bf the problem- oriented system. 4IhFing the weekafter the system had been implemented, the nurse investigator visited theunit, revieced records, and moderated sessions with thefloor nurses. A.
71'-64-
*'
chart on a current patient was reviewed.. Nurses identified more!patient problems and acted on them (nosource of comparison ornumerical results vere,reported).
A quesiionnaire-regarding the impact ofrtheePOR on practiceanswered by "about 50" nurses. .Most felt that the POR had increasedtheir awareness of the reasons for admission and isr the specifictreatment of their patients. They also felt that they had become moreskilled in identifying new problems and in seeking their causes. The --Inurse's role as teacher of patients becamatamore visible And moreintegrated throughout the patient's hospitalization. Most nursesreported more work satisfaction and an improvement in self-image. Thequestions, results, and framework of this investigation are signifi-cant.. The question of whether or not the teaching sessions conductedby the nurse investigator night have produced improved charting withoutthe POR cannot be answered by the method used ilithis study.
Manuals, Workbooks, and Forms
The National League for Nursing's publication, Problem-OrientedSystems of Patient Care (1914), consists of papers presented at a ,
workshop series. Many forms that were developed for use with theproblem - oriented record are included. 'Vaughan-Wrobel and Henderson(1976) differentiated between the problem-oriented record and theproblem-oriented system in their workbook. They described each andprovided extensive exercises in the use of the problem-oriented record.
<
The ViOting Nurse AssOcia5ion, Inc., Burlington:"Yermont (19/5),prepared an excellent training manual It was designed for hehealth agencies and is available commercially. It is reviewed in thesection entitled: "Methodologies for Implementing the Problem-OrientedSystem in Nursing."
LNursi Innovations and Adaptations the Problem- Oriented Record
One innovation in the problem- oriented record was sugge ei byDavis (1974). The addition of an "I" for intervention was incorporatedinto the SOAP note. St. John and Soulary,(19/3)suggested a goal-oriented, rather than a problemtoriented approach. They:stated-that'this produces a growth-oriented, rather than a pathology7orisntedapproach to care.
.1"
72*-6j-:
'to
Nursing Process and Problem-Oriented Approaches
A. fey articles deal with the congruence of nursing process andproblem-oriented approaches. Abruzzese (1974) believed that nursingprocess and problem-oriented systems are similar in t h is bothvery simple and very complex. Efforts to maintain e Jiff rentiationof nursing (diagnosis.aad treatment of human respo e to i ess) andmedicine (diagnosis and treatment of the illness itself) are deicribed.The Department of Nursing of St. Luke's Hospital Center, New York City,was able to gain acceptance of a nursing data base bythe medical ree-,ords committee after the problem-oriented medical record had been
adopted.
Bloom, Molbo, and Pardee (1974) used the adaptations of the problem-oriented system described in Bloom's previous article (Ameriean JournalofNursing, 1971), in which the components of the progress notes were
_altered to- be ooneruept with tlw.emixporteirts All.d'_xna;adrug_panceems-T.--(1)
.observations, (2) assessment, (3) goals and plans, (4) action, and.(5)evaluation. The major focus of the article was planning to implementthe change to problem-oriented n.; using the modified format. Plan-ning'for initiation of the system eluded: consideration of theimpact on the organization, (2) ponsibility, (3) accountability, (4)communication, and (5) preparati 618
jThe last Section of Bbowni n and Minehan's (1974) compilation ofarticles regarding nursing tnosess included several articles on theproblem-oriented system under the title "Future Trends." The similari-ties of nursing process and problem-oriented approaches are presentedin the third section; "The Problem-Oriented System and Nursing Process,"of Gene's mimeographed work (1974) Nursing problem and nursing treat-ment typologies ff.= Abdellah and others' Patient Centered Approachesto Nursing. are listed along vith the equivalent components of theproblem-oriented record to identity the similarities between these twoapproaches.
.
Lesnick and Anderson's list of six independent and one dependentfunction of nursing is also included. The elements that correspond toVle problem-oriented record are underlined. Convinced that the nursingprocess is applicable in any practice setting, Metthis (1974) statedthat the problem-oriented system is simpl;a nev name for the pursingprocess: If the underlying concepts are vtp. understood, a certainamonnt dr practice will make recordkeeping tampler and more pertinent(p. 50), The author then described the steps of the nursing process:(1) 04servat4on, (2) assessment, (3) planning, PO eitablishnentofobjectives, T5) interventionk, (6) evaluation, (7)'plan revision, and(8) total reiSseeianent. Mitchell (1973) stated, "The Problem-Orientedformat is an ideal vehicle for documenting all aspects of the nursingprocess" (p. 196).
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,
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Niland. and Bentz (1974) stated that nursing process and particular-ly nursing..assessment are interpreted differently by different authors.Various definitions are provided. All of the definitions, however,are consistent with the problem-oriented system with regard to theprocess of seeking information for problem identification and analysis:"problem solving, and evaluation. ."Tbe,prOblem-oriented., record," theauthors concluded, "can be used to implement the nursing process in anorganized and effective tanner" (p. 245). Nolan's (1974) descriptionof problem-sblving activities is such more differentiated than the fouror five components usually described. Nolan organized information-seeking strategies differently than most writers on the nursing process(often called "problem-solving") approach. She stated that a problemis f,iiist identified, and then information is sought about prior ex-periences with similar problems.
qlo need for documentation of skilled nUct(ing care for third:party payment provided the 'impetus for Thome wid Pittman's investigation(1972). Nursing process, based on the scientific method, includesassessment, planning, implementation, and evaluation. The problem-oriented record was chosen to facilitate documentation of theseactivities, and forms were designed to encourage nurses to follow thisformat. These included a problem sheet, nursing care plan, nursingnotes, and a flow sheet. The revised forms were evaluated accordingto the following criteria:
1. Were nurs4ng problems rdentifiet and listed on the appropriatefor-?
2. Was a 'nursing care plan formulated for each problem identified. and was it consistent with the nursing assessment?
Was the charting of nursing care related to the nursing problem?Was there an evaluation of the success of thf nursing carePlan? Could the patient's progress be identified from the rec7ord?
The article attempts to deal with nursing process and the problem-,.
erlented-record as if there were a one-to-one correspondence, ratherthan a high degree of similarity. Asa result, there is some confUsionwith regard to this issue in this otherwise excellent report of insti-tutingthe problem-oriented record in an extended-care facility. Thefirst chapter of the Washington, D.C., Veterans Administration Manual(1974) includes a section on nursing process approaches to recording'patient care. The, components of the nursing process are listed'as:assesament, planning, intervention, and evaluation. The nursing pareplan has improved patient care plsnning and raised awareness of theother components of patient care. Assessment has been the most diffi-cult component to imp rent. The problem-oriented system "is what the'nursing process is abofut"- and can iolie many of the difficulties
_
1in implementing this'approach to recording care of patients.
D. THE oolevrEuzib PROBSAEM-ORIENTED RECORD
Introduction
The probleth-oriented record is a-method of organizing patient-and patient care information. The computer provides the ability tostore, process, ind distribute information. The computerized problem-oriented record system provides, therefore, a method for-atorillg,processing, and distributing patient and patient care information.
Background
Theie is no mention of c terizatilim in Weed's first articleohitheproblem-oriented record which appeared in the Irish Journal ofMedical Sciences in 1964. A "Nev Approach to Medical Taaaing" (1966)maies d404ecific mention of the computer, but does include two con-cepts which are specifically related to computerization: better careresults from the availability of inforhation (p. 1036 in_ Medical Times)dad the mistake.of placing major emphasis on "feats" of =emory intraining physicians (Ibid., p. 1037). In addition, the problem-orientedrecord is referred, to as.a system, a word A;bich often triggers thethought of computerized-informati,on systems.
The first tarticle by Weed (1966) whiqtrspecifically nentiohzcomputerization of the problem-oriented record was published in the NevTongland Journal of Medicine in 1968. In order to deal with the frustrationak,in medical action, a moi=e organized approach to the medical record,-a pore rational acceptance and use of paramedical personnel, and a morepositive attitude about the computer in medicine will be required.Slack's work with.a domputerized form of history taking,' using direct,typewritten input; branching questions; and a cathode ray screen-Is men-tioned. This, Weed said, would guarantee every patient a minim') re-corded data base. The physician will always be eipecteTto enlarge thisinformation and integrate it with that which he-has elicited ilircelf."IA this way the recorded historical-data will not be based on a singleencounter with anyone and the risk of important omissions will be re- s'
duced" (pp. 595-96).
The manual problem- oriented record providei a basis for computeri-zation. The computerized form will allow all data regarding a specificproblem to le retrieved immediately and sequentially. Prepared dis-Plays.provide both ease and freedom of expression to the physician..
The prepared spluences of displays will train the physician t9-formu-late problems consistently, completely, and accurately.
Weed's article (1972), "Background Paper for Concept of NationalLibrary Displays," in Hurst and Walker, eds., The Problem-OrientedSystem, includes'sections by several authors. Laura Weed's (1972)section, "Initial Goal for the Development of the Medical Content ofthe PROMISSystem" (pp. 261-62), presents the goals and process ofdevelopment of the content of the PROWS System, primarily with regardto the ph" co/ogical content. "The abilityof the physician userto interact 'ire tly with the medical content . . . and the coupling ofthe- universe - medical content to specific problems are.-the two majorcharacteristics . which underlie the.-approaches to developing themedical content" (p. 261):,
Drug_infOrmatioittra'--,s^c._w_ara-dev-e-loped--by -a- physic-ism, tNelsoldland a_pharmar,qT
-"Fea.=-4eatly used d41.46b-were emphasized,since these are the usual cause of adverse reactions. Nelsen andBassett's (19'2) section, "use of the Computer in Arriving at DiagnosticPlans" ',pp. 262-64), deal=-with the procedure and frames developed forassisting the physician to develop his diagnosis. The conclusion tothis set of "sections" stated that: "it is apparent that the medicalcontent of the system can be viewed as a textbook or encyclopedia or-ganized in a structure deterMined by two'considerations:
1. The problem-oriented approach in whic current observittionsare systematically linked to -each of e patient'sTf* lems.
1?.
2 The computer tool itself, -which perbdts in overexpadttng bodyof medical knowledge to be coupled, via the computer, to eachof the patient's problems, not retrospectively, but 'on line"
265)*440'
Concepts and Philosophy
General
Hayes-Both, Longabaugh, and Hyback.(19 3) focused their,articleon the information new of a mental bospit system. The principlesidentified, however, are applicable to any care setting, whethei coverputerized er snot. As in any general system approach, they'are alsoapplicable at many levels of organization: the_hospital,the unit, orthe individual patient...care team. The authors stated: "The complexityand informativeness of the MIS (management information system) must notbe less than that ofthe system itself: Otherwise' the system is cal-strained to failure . . . (because- of) the inadequacy of the information
(-ota4rhich it bases its actions" (p. 320).*14,
-S 76 I>
-69- -
Feedback returns information regarding the success of perform=to those who originally. carried out the action (provided the care).Ideptification of the methods by which information regarding the suc-cess of actions can be returned to the actors is the first step insUring sucCessful care. This in-formation, however, is baged onremely complex patient variables. Applying Hayes-Roths earliernciple, it becomes obvious that the information-returned to the
providers -of care must include all of the complexities regarding the.1"patient,-as- system."
Information regarding the individual patient provides a microcosmer minisystem) of the performance,of the entire system. Four com-ponents of an information system which are especially relevant to thecontrol of the patient's care program are:
2. The problem,
Ea-Mat/on of the 'patient-,
3. Treatments and tests performed,
4. Proqress (p. 327).
The problem-oriented record provides' e-on -one fit tpi meeting
these information needs, and the problem-ori ted record cab supportthe triinsitionto the computerized problem-ort nted record. The
authors also noted a concept which is useful in avariety of settings.The differentiation which occurs with any sort of'specializatiob bringswith it a. simultaneous need for integration in order to keep theactivities of the specialized elements in accord with the goals of,.the system as.a vhole.
Weed and SChacter (1969) presented a list of the objections andquestions most frequently posed by visitors to theAPROMIS Laboratory.The questions presented and their answers include
1. The problem list frequently results in fragmentation ofdiagnostic entries, This is answered by the statement that,"11-a complete prmlysis is done On'each finding integrationof related findings occurs'clearly and inevitably" (pp. 275-76).
2. It would take forever.tftlist all the problems on some patients.Prevision of one problem, "multiple somatic complaints," inthe computer, em provides for this pattern (pp. 276-T7). 7
14,
3. The problem-oriented record demands toot much data and is there-.
fore too timeconsuming, rather than'allowincthe physician toscreen for the relevancefog eaeh patient complaint Theanswers are: 1
a.) The problep-oriented system doei not require a certain1
4
A-
Sf
,. size data base, only that the data base be specified,
"Incomplete data base" may also be considered as aproblem to be entered on the problem list.
.b.) The physician should establish priorities and diiect'his attention accordingly.
c.),Insufficient time is an-argument for the use of pars-pr6fessionals td perform such tasks as gathers thedata base (pp. 277-78).
4.40A specialist does not have the time to create a completeproblenlist. A specialist functioning as a consultant shouldhave the problem list presented to him (pp. 278-79).
5. When computers or paramedical personnel record a patient'shistory, the nonverbal communication between doctor and patientis loat,a.) The physician can repeat those parts of the history that
seem to require personal communication.b.) Thinking that nonverbal communication is beneficial to
eliciting s full history is a mistake.et.) Comparison of computer-obtained and physician-obtained
histories shoved th the number of facts gathered by thephysician and not th computer was quite small. Emotionalresponses were rare'inyticientg record, but wereelaborated in detail in the computerized record.
Other questions related to: emergency situations -3n which thecomputer is a tool, improvement of the quality of medical care, .expense(which is countered by savings from the indirect costs of missed prob-lems and lost test results), the, synergism Of the interaction betweenbits of information for cost accounting, and memory and the implica-tions for medical education. following exercpt from a grant sppli-cation by Weed (1973) identified the goal of the PRO MIS system to bef
-"Establish-for a defined population and their health care providers ahealth information system with a feedback loop for corrective action.The system must all& evaluation by preserving of only thedata--but
'the logic of all decisions recorded' in the system" (p. 93)./4
The six central principles of the PROMIS group are quoted:
1. The basid for the health care information system is a single -unit health record kept for each member of the populationfor his:entire life pan.
2. The unit health record is organized so that all problemsare immediately apparent and so that not only what was donefor eacti problem but why it was done and vhlt the resultswere are discernible. .
4;
.13. The basic tool medical.' personnel use to create ,the unit heilth
record has built into it the currency Of information and param-
:78-71-
,
eters of guidance reducing the user's dependency on memorywhile alloying him to participate in the system's growth.Such-esystem requires computer technology to manage themassive mount of information.
4. The form in which unit health records are stored in the systemmust allow efficient retrieval for both individual recordsand groups of records to be used for poeglation studies.Preservation of recorded medical logic provides a feedbackloop for the audit of both the user's performance and the.system's functioning._
5.. The unit health record is accessible' around the clock at elllocations where health care is provided.
6. The syAbm's building blocks (hardware, instruMkntationimft='ware, medical content sOftware) permit expansion or contractionto serve many different medical setting and geographic areasin a manner that keeps qitrAity constant as the scale of theoperation varies.
Thy major 6ontert piesented'in Cantrill's article in Hurst andWalker. (1972) is that of the.computerized.problem-oriented system,asa force for the integration of information regarding patient care.
Synergistic effects would result from the relationships between` differentbits of information. Information regarding all aspects and all settingsof an individual patient's experiences with care would have a powerfulimpact on the qmoity of care-r- Ethical issues ih the allocation ofresources resulting from population studies could be considered inter -gently.
meN,
Chapter 10 in Weed's Medical Records, Medical Education, and PatientCare (1969) was prepared by Stephen Cantrill. He stated that the com-puterization of the.pedical.record can be an aid to every phase of medi-cal act.on. The computerized medical history:
1. Has clearly defined content, independent of the physician'sinterest, time, and competence;
,
Does not require any eXpenpture of a physician's time;
Can b' checked by the physician for accuracy;
Guarantees a minimum data base;
5. Is legible (p. 110).
High -speed branching questions allow a dialok in which eadilhOstiondepends on the patient's responses to earlier questions (p .141. Problemformulatio9ris also facilitated by branching. Some infoimatiqn is gained,
4-
4
and some is lost in the computerized approach to history taking. Rele-'want information, however, can be typed irate the gYstem, or the stan-dard displays may be altered' to include it. The squicce of dispaaygmay also be altered. Some physicians prefer to isalle general symptomssuch as weight loss, -fatigability, fever, and malaise before beginning_a detailed analysis c4one symptom. -There is evidence that such amethod is useful in prognosis (p. 117).
Computerized accounts provide a certain sameness of expression,which some physicians feel loses a certain delicacy of expression. How-ever, it is the combfnat
-
s of descriptors which provide' the unique-ness, and the zoasibilites are almost endless. vArt",was never malt"to be applied to undisc.,clined casual accounts . *. true art lies in
..he magi-a-4ve interpre atiod of, and action on, multiple variableithat are defined consist f4.7 and analyzed accurately, The applicati6nof the computer to clew has not been successful, becausepatients do not provide eitner single or mutually exclusive problems.
The computerized Problem-oriented approach can make a dynamic cost-accounting system possible. Specific utilization of medical resourcesand costs can be identified. The introduction to Weed's Supplement toMedical Records, Medical Education, and Patient Care:(1969) providesvaluable concepts and philosonhy regarding the computerized problem-oriented system. The concek of information as energy (credited toPeter :Tucker; is presentea in a clear and engaging manner. Differ51-tiaticn between the distribution and the production of energy,is drawn. 40The statement is made that 'the computer allows a'speed and multiplicityof corrKationzof action and knowledge never before attainable" (p. 5).The remainder of-this work is a detaicled 4escription of the systpm
followed by a conclusion, "Educatiod, Medical Care 'and theComputer" (pp. 16L-'1).
:n his article-, "Technology is a Link, Not a Barrier for Doctorand Patient" (1970), Weed stated that information is energy. The__
4o-f#r evallabi-Itty of the informiticnal energy what theelectric light and the motor did for the availability of electricalenergy. Before the computer, "there was no central superbrain, completeand up to date, acting
as a standard to which 'all could turn" (p. 81).Prior to th.t-computer,
the central storehouse of "information energy"was the medicate library; now it is Pbssible to develop a library ofdisplays rich can be linked to a variety of problems. The lates for-mation, precautions, and options become iMmediately available to thePhysician who uses the computer to define the problem or treat thepatient.
A communicatiohi system ..1,riking the present independent, uncorre-lated islallIds of intellectuar tivities will, it is hoped, reinforcethat which is right and force bandonment of that which proves false.Students should be requiredit change information displays in the com-7puter, documenting the evidence as they do. . No individual takes com-
1so-73-
plete c e of the patient; a whole system is required to do that.
The iss of sympathy is raised. Arne( kind of sympathy, in whichthe in vidual "knows what to do, has 'the courage and ingenuity todo it, d the good nature to be Willing to do it (p. 83), is /assents 'to make sympathy constructive.. On a larger level, concernfor soc problems, coupled with technology, can likewise be,turnedinto constructive action.
f Graves (1971) identified the problems encountered in attemptingto desfgn a study to compare theseffects of the computerized problem-orienteld record (C.P.O.) with tlirnual, source-oriented record.(M.S.0j). Three problems were i titled:
1. Identification of operational de
2, The ,lack Of ,a conversion factor
' at two different -times and withmeaSurement, the M.S:0, and the
3.-"Identification of the effect/of tlie measurement on themeasured (Modern Hospital, p. 105).
,
In order to measure the quAlity of care as reflected in medicalrecords, the records must b4-similar.with regard to:.
finitiot
for the states, of medicinetwo different scales ofC.P.O.;
1.. The range, detag, organization, and availability of the database;
2. The degree to which the logical pathWays are evident.
M.S.O.'s are not so structuredwith other -M.S..0.'s or between
addition, the form and contentaffect the quality of care.
and th;refore cannot be compared eitherM.S.O.'s and other record formats. In"of the medical record does, in itself,
The. C.P.O. is a powerful tool to improve medical reality and thequality of care in a way that is not possible with the M.S.O. record.
.Weed's presentation at the University of Colorado School of Medicinq("Not As a Spientist," 1967) compared medical practice and scientificresearch. The physician is often confronted with urgent clinicalproblems in clusters. The computer may offer a way out of the con-fusion of information currently recorded fn the medical recordAk
. 11"
Confidentiality
Weed,("The Public's Neekis Must "be.Mst," 1974) stated that the con-cern regarding confidentiality should be secondary to that regardingthe ability to obtain andscommunicate adequate inforaltion for patient
%care. In medicine, what you don't know Can hurt you. There are ttiot,
ways to- approach the problem of confidentiality:
1.. Conine the flow of ra cal inforiaationexclusively toaccredited and prope ly motivated providers of care,
2. Worry less-about it.
, "Confidentiality is just another word for secrecy" (p. 23), andpreoccupation with it is counterproductior. The abuse of 'information,may be-eliminated by teaching children how to deal with personalinformation fairly and wisely. There will never be arsystAwhich .
guarantees perfect confidentiality while simultaneously providingcoordinated care fbr an individual over A period of time. Providingindividuals with- their evn medi-eta-retOrds-mlar-a1130 th-alfge- theattitude- about -what irrformattun
-should- te- tettSidefed -it-private .1"- The:-"Nindividu.al would have information 'about the causes of his own health
.rotflems and be more tolerant of others 1- health problets. If therewere greater openness and candor, there would be less,,need jfor secrecy.
The issue is raised as to whether or not any health fessionalhas the option to exclude information about a patient from is recordif he thinks the care will suffer. Fears of invasion or privacy maycause some patients to withhold information. Society's long-term goals .
conflict with the individual patient's' need fol. privacy. "The bluntfact is thatOthere will be times when society's needs Override those of,_the indivic!val." The fphySician walks a tightrot$e between these con-flicting demands" 1p. 26). Good medical care can result only fromgood medical info tion.
Rumsey's (1974) opposing viewpoint is printed next to Weed'scuticle in the same journal. Any centralized data bank saves spaceand handles information more efficiently, but raises tree vital quest.tions:
1. How trill the information be used?
2. Who will control it?
3. Who vill pays the bill?
f
Data acquisition and sale are big business. Third-party payers,government, or private insurance companies elaYelop screens and profilesof patients in order to evaluate care and to determine payments. The"exchange of information should be limited specifically-to those with alegitimate need to know abogt.some aspett of a patient's situation.Patients' confidences can be kept by ensuring- that:
1. Good records are prepared, and their sec ira protected.
Records are Aurrend'ered only when one is presented with it. ,.
82-75-
-4.
.-properly executed subpoena.
v , k ,. 3. A well-edited summary,is sent when .it im legally Proper to. ',
- -
do so. ,
4
..64^
. ... 1 so. 4. Peer re5tiew mechanism's are k6pt in physiFians' hands.
, ...
.- . .
in cox cludion,the author statjeir Our responsibility frill alyaya beour individual patients--and-acrucial aspect of that-resibnsibility
is the protection (4 confidentje.elitr-(p, 261.,* .
N-
Empathy . -,
computers
"Co mputers end Ccdpassion" (1975), Weed refuted the objection.
that take the compass .n out of medicine. He stated %h$:"We've all read the science fi ion that tells of times in.the futurewhen persons with4the most 11.!.' ing injuries and illnesses are inthe care ofantl:Nlible mawine which painlessly ymak0 them liienew. Can you) e any itgison really.sick or in paip who wouldn't-yelcoma such a mirkcie?",(p.-95). Nies (1973) objected to the valueof the computerized problem-oriented record on the basis of the lossOf the "critical,interfacd ketween the dat4 collector and the patient."As a result ofithe loss of thissinteraction, the information Aiiinedis less valuable and ",bad data recorded in bad language* beom4 Partof the "garbage ingarbage out" syndrome.
Gertzog a970) compared Weed's probli oriented and Acheimedical record linkage system. The primary area of similarity itheir underlying value systems. -Both stress the role of medical ree-txds as a tool for imiroving phient care. Achepoilssy6rem (p.677) ..ftstresses the need for linking information 416out tients obeainedfromdifferent care settings. The alihor suggested that the proSle9-oriented.strtoture migV provide- the mechanism for selecting the 4nfor-
it *c,mAtiod to ,be linked in.Acheson's,systed. ,4
VP* .V
Aro o,
Descriptions of the Computerized Pr
r
nted System
,,
POrt 7 a Nurst, and-Waller'S bOok,(1972)AncluddiCrourerticles'on,the computer and the problem-oriedied System, with artTeleg.bySchUltz, Cantrill, aDd Morgan (1972);.Dane (1972); Weedand others "it,
(1972); and,CantrillF(1972). 'Schultz and other (197?) stated that ,.., .tthe "paper" problem-oriented record provides the philottophicalbasiej
...
for the co4uteriAed system:: Computerization, kowever, "augment'i 'itsmedical capabilit.ps by making it passible to /retrieve all data giltone problem i n s ,kue4pe and by allaying date: td be organized separate- ' ,
-... -Is,. , .P' .,
k. ~y.. 0 irs'4... . !.2t
.1. 83. ,k4
4. 46_
-._.
ly from ita source in the record° (p. 203Y. it.enabl#s the audit of .--
__patients mith similar problews or of ,a. physicidit's logic inthe treat-vent of one patient's.problems. , .
.. .
-The work of the'EROMIS Croup vas originally built on the system__being-developed by Medical Systems Research Laboratory of bontrol DataCorporation. -A description of the compUterizedproblem-oriented rec-ord system is included. Descriptions of'branching displays, he logicof assignment of information to, categories, and methods for'ilt4 retriev--Id of information are presented. An extensive efcample of a patientrecord provides both-an understanding and a feel for.the content and-the Organization of the computerized problem-Oriented record. Theauthor conclude "we are findiginmedicine through the computerized'problem-oriente!'record . . . that the amplification and interactionsamong the components,of the system may at times be"more important thanthe.coponents themselves",(Schnitz and others, in 111.1rst and Walker;P. 249). .
. t_
... ,
Mittleri(1972), a physician from the Duke University School ofy..,.Medicine, reported his visit tothe computerized Ob-Gyn unit at'the -
Mediftl Center Hospital of Vertont. His description of the cui:ren.-isslies in the use of the computerized,problemokented record includesboth positive and negative aspects. After presenting the probio-,* .oriented record and its applications to nursingoPhillips (1972) dis-ctissed
-,
tht computerized problem-oriented record. .The online converse-.tional interaction between the-phy5ician and the computer fW combination
:with the branchivg displdYs allows the physician to pursue only thosetopics he
-chooses. -
.1
y
. Walton (1973) definedJBOyIS a.z. 'a computerized,,, online, display-I, , .ilateractive, medical information and, record system argailized,pndthe.principles ofdpe problem-oriented philasOphy" (p. 10). The
PROMIS system, "including the -terminals used,:the display'frames, and. Jthe current stft of the development of the system, is described.Ine implications of t,he PRO IS system are presented. These include thedecreased 'need for memory of medical information, the.currencObf medical,.
information whiah,can be maintained with the system, the ease of quality..control and audit;, and the value .of the system for,researq. andbplinning..,.Walton stated the4: "meaningful and comparative data ball% will exist45'large numbers .of persona and Will per it extensive investigations-into correlations and patterns.of findings and prOblems, and processes
, and outcomes" (p. 19). It will tlerdby,enable more rational healthservices- planning and resource ailbcation. \L._
.
Weed (Supplement to Medical Records, Medical Education) and PatientCare, 1969) presents the most technical description of the compiateritedproblera-oriented rhe three basic- functions of the computer areto
,1
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.
1.- Provide the branching fraM6rork,.1
,I,e
% .__ e . \., ' . A .:- .
$ ' '84 .
. .,-17-
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io
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2. Translate'the selecti o data that can be read or stored,
3. Retrieve data either n the screen or on the printout.
An overall description of the = em, the use of the SETRAN interactive.program, a glossary of terms, and a detailed description orthe contentsof the frames for recording the physical examination are provided. .Theinitial pages are.an invaluable resource for those interested in develop-ing the technology for a computerizedproblemroriented system. Thebulk of the information relates,to the specifics of the physicalexamination.. In one section of Your Bealth- Care and How To age It,Weed ("edicine and the Computer," .1973) noted the importance o thecomputer as a resource for reducingthe limitations of memory- asedmedical care.. An extensixe example of the process is prove for apatient with comeq.sints of nervousness and anxiety. 4'
,Components
-SSC_
Data base.--Cantrill's appendix to Weed's Medicat Records, MedicalEducation, andPatient Care (1969) presents the questionnaire developed, "as an initial' attempt in tie constrpetion of a cathode-ray-tube-based,patient-ad tinistered, past medical history and symptoms revieik(p. 133).
1 The frames used or the physical examination_componenfof_the Attalbaseare presented Weed's "An Atlas of Physical Frnmina:Cion Abnormalities ";(19691. .A ques ionnairewhich caM.be used for one past of the-database is reproduqed as the Appendix to Weed's Your Health Care and How ToManage It 11975). This can be used- either manually Qr in a...computerized_form.
4
f .
ttoblem list.--No articles specifically 'elated to the problem listin the CPOR were identified. .
'Plans.--Nelson and Bassettz11972) presented the "Use of the Computerin Arriving at,Diagnostic Plans in Weed's "Background Paper for Conceptof National- Library Displays" (pp. 262-64). to. -
=3
Progress notes.-Camput ec. displays are shown inCare and Haw To Manage It (1975).. 'These retied% thethought that the health care provider should have to4` 1116 J
Weedts Your Healthminimum outlines ofgo throUgh.
nitiation and Acceptance of the Computerizei..Problem-Oriented
-System
_
Doeldson (1973) stated that the acceptange of the manual problem-oriented record wag rapid:. However, acdeptance of the computerized POShas been much slower. The medical profession_wi4 first leartethe
85
id
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manual problem-oriented system and t. en proceed to its computerizedform.
Applications of the Computerized Problem-Oriented Record
Applicatiods of the computerized problem-oriented record have beendescribed both from the-viewpoint of its value to the functions or auditand educatibn and its value to different settings and services.
Audit and Education
Conway ( "On the Significance of the Problem-Oriented Rec in,Quality Control of Health Care," 1973) stated that tvo Conditior, Arenecespary to enforce correspondence between the process of careand therecord. The computer must be:
1.1 Convenient touse;
2. A.contributor, used concurrently and not just "after the fact.!
One contribution of the computerized problem-oriented record i in the,presentation of options at every point involving a choice in the careprocess. The logic proceSses presented to the user by the computer aremore co4rehensive and more in line with the .current state of the medi-
....cal art than those which could be preserved An his own memory prp. 87-
The health of the individual'is a complex system I./hose state isma4fested by the values. =May 'measurable variablei. When A set ofvariables deviates from it in asrecognizable way, "we attach a name tk:
-this situatiop, and call it a problem" (p. 85). Silberman's auditsessions (iniWalker,'Hurst, and Woody 1973) with medical sttdentspressed him that the qUality of thei workups clearly.improved dving.the 2 or 3 weeks,inrwhich they worked with the computerized problem, -oriented record on a unit.
rr
Settings. and Services
kialton's (1973)"oveview of the computerized problem-orientedsystem stated that the Cr OR is being used at the Baltimore PudicHealth' Service Hdspital and' ft the Brunswick, Maine, Naval Air StationDisp sary. quasi-problem-oriented systems are used by Octo Barnett,Jiarva06Commuhity Health Plan, Cambridge, Mastiachusetts;.and ShannonBrunjes, Community Health Care Center Plan, New'Haven, Connecticut.Brawnd.and Morgan 1(103) preicnted the specifics Of the development of
.86-79- ".
a computlerized operative report for medical menisectomy.
Studies Regarding the Computerized Problem-Oriented Record
1"
Brown and (in WalIcer,',Btrst, and Woody 1973) sent the,comrptter program for the menjaectoFy procedure to a group' of 392 randomly '
selected orthopedic surgeons. These surgeons were asked,44,oftvaluatethejlevel of importande of the items.' In addition, the aeons wereasked to` submit dictated repdrts for analysis and compar2fi,on with thecomputer program. Twenty-five reports were randOmly selected fromthis group, and 25 were randomly selected from the records of the Medi-cal Center Hospital of Vermont. Frequent omissions of important infor-mation and inclusions of unnecessary detail occurred in the dictated,reports. -
4
Schmidt "x(197$) investigations regardipg a computerized system,"beset on the.problem-Oriented record and used at the Brunswick4AirNaval Station, Maine, shoved that physicians pent a longer time (12rather than 10 *nutes)with each patient. A comparison of 318 manualsand 113 computerized records of patients-with acute urinary iTrictinfection shoved dramatic results. Magf`more laboratory tests, s,and consultations were required for the "paper - record" patients than .
for the computeriied-record patients: The patients who received care.under the computerized system received many more simple, appropriate.-tests the paper record group. Conversely, the paper record groupreceivr:ore "higher, order" procedures in .terms of trauma and expense(IVP's and consultations). Krismer and Cordes (1970) investigated. he, -
care received by .five intensive-care patients under a computerizedproblem-oriented formats 'Traditional charts 'were maintained. Situlatedstudies demonstrated that accuracy and efficiency of care increasedwith the computerized_ problem- oriented system. So puri!.rical resultswere reported.
E. -NURSI4 AND-THE COMPUTERIZED PROB11*-ORIENTED RECORD.
. .. ./.,..0 p ,
- . - (\
-' Introduction .
.
'Saba and Levine's paper (1976) outlines general concepts regardingthe'use of computerized record systems--primarily as applied to publichealth agency use. They provide a;briet background of the .developmentof information systems from verbal through Written, and,fourgenerations computer systemd. The four-basic modules of .nformattonAre presented for use in comity health: These would seeT no less
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applicable to hos tal settings, although the specific information An-eluded would need to be altered to, fit the setting. Statistical infor,-matimn, billing infdrmation, patient assessment, and service evaluationcomponents are described,. The goads of the PROM'S system include allfour of thesetaspects. In addition, the PROM'S goals include thepoAntial for, gaining valuable information from. the interactions betweenthese components of an information system.
Experience With the Computerized Problem-Oriented-gCord-
Tvo articles veie identified with regard to the use of t 'he com7.'
-puterized problem-oriented record in a nurO.ng care setting. Both werewritten by Donna sane, who vas the head nurse od the Ob-Gyn unit atthe ''dig cat Center Hospital of Vermont, vSere the computerized problem:- ,
oriented record vas in use ?ram: Juay 19'0 until NoveMber 1974.. Gene'1972; is the ma,lor proponent of the ocomEuterized problem-oriented rec-ord'4 for nursing care.' In her article ilerhe Proble6-Oriented System,
she described the use of the CPU o the Ob-Cfyn'unit at the MedicalCenter HosPltal 6f Vermont and desofibed its advantages in providingcare.
our te..:inals were used by all staff "inters to enter ancl-. , .
retrieve la,ta. ire patients completed the computerized data base priorto admissicn, This prodded an opportudity to begin a relationship,between the n-arse and the patient end to answer the patient's questionsahsu: the impending surgery. The computerized prob1e list was printed°sr each patient aftd used as a worksheet for pianning.and deliveringcare. A terminal in the operating room provided information regardingpostoperative ord while the patient was on the vay back to the unit.The csmputer provi d, the potential for relieving nurses of managert1functions. It also taught organization, logic, and fact. Patienteducation was one of the areas in which the computer was of greatestvalue. :A triiTeat$, of discharge orders was provided to the patient prior,
discharge.' The patie;t profile vhidh vas used is included. Vital111VpPearence, cooperativeness, mental state, activity, typical t,
bresent -odications are among the items *naked. Spaccis.pro-o record (type in) the nursing care plan.
-n.13. more recent article in Your Health Care and'HoU TaManageM3. dahe f1975) focused'primarily on the issues related to unit manage--;APIt and the dvelopment ofthe system from this poine4of riew, Thecomputerized pfbblem-oriented record =was. an aid to the nursing staff..It facilitated their vork, while often making the work of the physicianmore aerPUding. (For example, operative reports were entered on thecomputer immediately aflen surgery, vhile tne patient vas on the way%back £o the unit.) The tasksoPunit management, coordinatio,oi'serNices, paper flow, etc., Are greatly facilitated by the computerized,system: Nurses used the'prob!ic list and the computer.softvare ex-
,
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tensivelyz,and as a result, asked more questions of the physicians.This was often perceived by the physicians es being inappropriate.
Nursing contributickn to the development of the system-occUrredboth by direct development of specific sections ana by continuedfeedback to the PROMIS Lab Although there are no separate sections onnursing,scce sections are used more by nurses than by members of otherdisciplines. Content developed-by.nursing.includes:
,to
1. Nursing' goals, Procedures, and plans by body system (plans).
2. Subjective and objective data fOr postoperative patients(progress notes).
Preoperative and .pos ive teaching for gynecology pro-.cedures, diabetic tear , breast,self-0YPonination, andcatheter care (progress notes).
With regard to Fntftt, the cc pater adds the felloving advantagesthose of the FOR:
1 Correct form is facilitated by caieputerization;
2. 'legibility is guaranteed by the computer;
1.*
3. Thoroughness is enforced by_cocputerization (p- 105').
The computer -has the-potential ability to catalog-and correlate datato determine patters and trends, to formulate statistics which will -
be helpful in studying effects of care on whole populations" (p. 105)The challenge . . . . . to have the insiOt and vision to'reorder our loyalties and responsibilities; learning bow to embracetechnology and control it so that we can turn idealistic concern .% .
into constructive action' (Weed, "Technology Is a Link, Not a Barrierfor Doctor .and Patient," 1970).
M.144ARY AND CONCLUSIONS
Nursing is a complex, goal-directed activity. goa) ofnursing is the facilitation of health and the reduction of the'fiegatiiveimpact of disease on the clients of its services. Nursing strat;gieiinclude consideration of the nurse, the client, their iiteracti6n, andthe etvironment. b'contilbutes both nets andresotirces to .the careprtocess.
the- an
They
the nursing tomPoments of patient care provide'ona method forsis or the Activities of nurses on behalf' of them- clients.defined differently' by various authors, bait may 'be considered
2or
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to include the following elements:
1. Information gathering,
2. Organization of information into mednings
3. Establishmeht of goals,
4. Planning strategiessto meet goals,
5. Intervention,
p
nt,
6. Evaluation., ,.
.
These compeneffes of the nursing procese are consistent vithta*generalr
systems approach to goal-directed behavior.N
The coMplexities of human needs and resources, however, do notTit the general systems approach to behavior directed to'a angle,statics goal. T Human needs and resotu.ces, are many, baried, and constant-ly shiftingcomponentsin behavioreach other ifility of the
they interact with each other. As a result, the nursingpatient care canncAbe considered as consecutive stepsRather, they toc,must remain in constant interaction witthey are to adequately reflect the complexity-and flexi-human needs that they have been designed-to meet.
,R3. Thenproblem-oriented record is a method for the o
of palierrt-lafarvxtiOnTind-patierrt- care iartittOribn. Thispublished by Weed during the 1960's. It 'emphasizes a form_vhiCh is organized into four,copponents:
1. Data base,
2t Problem list,
3. Initial pitpeis,
4. Progress notes:*
a.) Subjective updating of they data gathered,b.) Objective updating of the data gathered,c.) Assessment,d.) Plans.
-4 The central meanings
requires management). P1ace riling to problems. ThvOibility of:
444
this system are "problems' (anything tintand patient responses to these are organized
e goal orthis'system include. increasing the
nationvas firstor recording
1. The interaction of, the pafrs.problems;p
e4
'2. The patient's response to treatment received;.
to
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.
,
.t
.
3. The. quality of care, including:..A.) Thoroughne.s*,
b.) Reliability,c.) Analytic sense,
d.) Efficiency of the providers 0.2-care (Weed 1972).
The bulk of the literature ,regarding the POR falls into threecategories: (1) descriptions of the system, (2) assets of the system,and (3) applications of the systemto various settings and services.Studies re riling the problem-oriented-record indi4te that'.'
1. Many phylans were not familiar with' the system :.n the early1970's (Iverson.and Yarnell 1972). v
2.
2. Mci.e pralemq were ""tif40344 when th° PCs y-- used to fih1it was not (Aranda 1974, Narang 1973, Gledhill 1973).
.
J _3. Auditability was not shown to be improvedthe.factor of legibility vas controlled (Fl
Physicians who ree'pond to questionn4res are genereily favorabletothe pystem (Campbell and Cooper 1973, Asp, and Brashear'1973,.
*he system whencher 1974).
Gledhill 1973) xs.
4d /6 difference was found in theme length of.time required to
identify, treat, or 'resolve the prOblem of anedia when the i
.
identify,
system, as opposed to a traditional system,was used (Ssiliz 19751.--
1The main asg...bif the system is the organization and visibility ofoatient Care information. Greatly decreased duplica}ion,of laboratvyservices restating from lost on misplaced laboratory results was ,
locqmented '(Aranda 1974).: Another study directed to medical educatipnind;icated. that the experience of using the POR for audit pfocsdures in-creased students' facility at data collection and 're according tothe POR format Sheehan, and Stickley, in Waker, Hurst, and %wooti'1973).', .
.
c '
The problem-oriented record has been adopted Sy nureing forcare in a variety of settings'and'services. Literature regarding -theuse of the FOR by nurses and for nursing care falls into the gamethree,major categories as that the POR in general...Descriptions ofthe system, its value, and its nitiation and application to,varioussettings and services constitute he bulk of the literature. Studiesregarding application of the POR i a nursing education setting showthat 'thOse students who have -been tp.ught.the use of the POR have greater'facility in problem identification in a clinical setting and greateradherence Vp the content of the POR'format (Mitchell and Atwood 1975Other studies (Savett and Good 1973) show that more patied) problemswere identified and Attem.documentat19* of nursing care occurred when
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the problem-oriented systamwaa used (Thoma and Pittman 1972, FQSp 1904,Bertucci, Huston, and.*rloff 1974). Improvement, in patient ware vasperceived by the nUrsis who used the system (Asp and Brashear,1973)and increased wdt satisfaction end improved self-3mAge occurred withthe use of theP0H-by nursing (Savett and Good 1973).
41(
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5. The computerized problem-oriented record ddds to the value ofthe POR by increasing the speed and amount of information which can be
organized, The potential for research,accounfability, and public education is great. Concepts, philosophy, .
and descriptions oT the CPOR constitute the bulk of the literature.regarding this constantly developing system. Studies of the OPC andclosely related systems document the validity of the ''rases developed*for the menisectcmy procedure (Brown and Morgan; ii Walker, Hurst; andWoody 1973) ani slam: the 411111 the CPOR in rclatApn to acute urinarytract infection. Completion of more basid procedures and fever higherorder procedures (IVP consultation} were conducted for patients afterthe initiation of modified CPOR (Schaidt, Schell, and Morrison 1974).\
fr
6. The commUterized-problem-oriented-record has been used bynursing in only one care setting. This setting was the Ob-Gyn unit ofthe Medical Center Hospital of Vermont. Two articles report the ex-
,
erience of Donna Gape, who iyis head nurse on the unit at the time.
'. The pro blem-oriented record is-largely compatible with n ursingprocess approaches. Goodnesfof fit is greatest ls the areas. of .in-formation gathering, assessment, and planning, and although present,is weaker in the areas of goal setting and interventidn.
Conclusion
V
In theory, nursing process is largely'dompat iblevith the compu-terized problem-oriented record. The basic organizatiOn of the problem-oriented system is.laigely compatible with nursing process approaches.Addition of a list of relevant assets 'Mazur 1973), inclusion of goals(St.John 1973), ,and Trrovision of a format for intervtntions (Bloom19T1) would complete the areas needed for congruence with profesbionalnursing approaches. However,.goals,and plans by nlIrseK can show sound,
.Emaiytic sense only if they ate made for patients' probl which 41*
nurses mAnAgerather than for eedicai diagnoggs. Document ion ofthe nkage between nursing care'prnblemt, nursing plans, and patient .
xes naes'has implications for third -party payment. Some currentapp,ications of the system provide a barrier to such d litkageclosing the opportunity to doonment.nUrsing activities for joati prob-lems which require nurting mano4eme Thejse ofthe system ii publichealth agencies does allov4 independ nt recording by.AUses and,fact' tate third -party p nt for.nursing interventions (Davis 77).
le
The computezed prOblp-oriented system offers aunique-oppor-tugity to"gather, organize, and distribute 'patient information and
l patient care informatioh. Individual and group accountability, and'repearch regaiding-the multiple.factors which contribute to disability,would result As,a consequence, public education would be enhanced', -
and a ford intelligent distribution of resdiarces,could occur (Cantrill,in Hurst, and Walker 1972). To maintain the ivalUe of the problem-ariented record as a constructive tool for 'patient cafe, it will benecessary to:
.1 I1. Rec ognize t nOL.ds.and resources brought into the care
sitUation by l aspects of the System --the aurae, the client,their interaction, and the environment.
4
2. Use the problea-oiiented-iiystern in a manner which is congruentwith a basic accountability to patients And families.
3. kfaintain the awareness that.the POR or the,CPOR is a means,Apher*thanan end, in patient care (Kramer 1972).
A
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:Pr
Corn"'""4",-1/ LIST OF BIBLIOGRAPHY ITEMS BY CONTENT AREA
101It
A' list- of Bibliography items, organ zed by content area, is,presented on the folldwing pages. It ntended to assist thereader to.. identify sources of information re4arding a particularcontent area. Those .articles relevant to gPspecific content areabut not reviewed in the text have big; in6luded in this list ofitems. j l /
-
The first column A an item numb r5,from the bibliography whichfollows this section. -Itis inters to- assist the reader to locatean item with its full facts' of publication in that lists The second
gives the nage of the primary suAbor of the work. Onlythe first author of any listing is giveA in the interest of space.The Index of Authorsvhich follows the Bibliography includes citationsof secondary authors. Articles by anonymous authors,areistedalphabetically in the biography according to the first or wordof the title.
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ITEM PRIMARY AUTHOR
'NURSING PROCESS
Backgroundo
'18 Abdellah, F.G.,2 Bonney, V.
3 Browning, M.H.'22 Chambers, W.24 Daubenmire, M.J.27 Durand, M. .
. 5 Freeman, R.B.28 'Fry, V.S.
32 Gruendemann, B.6 Harmer,.B.
282 Havken, P.40 Henderson, V.
Kdeedler,"J.45 Kormorita, N.47 = Levis, L.
10 Little, D:48 Little, D.
55 "Mundinger, M.O.56' Mundinger, M.57 Nicholls, M..E:r
14 _Nutting, M.A.
59 Recording...60 Rothberg, J.S.61 Hoye Sr. C.62 - Rubin, C.F,64 Smith, D.M.16 Tura, H.
Yura, H.
612 Yura, H.
69 Zimmerman, D.S.
"Components
InformationGathering
2 Bonney, V.
,29 Garant, C.
33 Hamdi, M.E.37 sHammond, K.
'9 Levls, L. .
51 McPhetridge, L.M.52 Manthey, M.E.
53 Max:shall, J.C.
15 "' Ujhely,
r
rm.
ITEM f PRIMARY AUTHOR
Assessment.--
25
27
33
Beiniriger, J..M.
Durand, M.
Hamcj.i, M.E.
34 Y Hamiond, K.
35 Hammond, K.36 Hammond, K.,41' Kelly, K.J.
42 Kelly, K.J.43 K.J.
50 McCain, R.F.56 Mundinger, M.O.60. Rothberg, J.S.
545 Vickers, G.17 Yura,
Goal Setting,
19 BlairoK1c.24 .Daubenmi
V10
. 11514
56
6o65
66
1769
'Planning
11
e
Li 1
, R.B.
L.
, D.
Mager, R.Mauksch I.G.
Munding , M.O.
Rothberg-; J.S,
Smith, D.M.Wagner, B.Yura, H.Zimmerman,, D.S.
3
21ofBrowniAg.,
CarlsW, S.
2 Ciuca, R.L.6 Harmer, B.
39 Harris, B.L. 411.
40 Henderson, V.
7 . Jensen, D.M.46 1:2 =64=1 M. to,
9 Levis" L.49 Little. D. .
-88-
Mayers, L.G.National ague...
I.
-
ITEM # PRIMARY AUTHOR ITEM 1' PRIMARY AUTHOR
.58 r Palisin, H.E.60 Rothberg, J.S.63 '. Ryan, D.J.
. 66 Wagner, B.M.17 ura, H.
Intervention
1
24
2b
5
30
912
611767
Abdellah, F.G.DaUbeivire, M.J.Deininger,Freeman, R.Gebbie, K..Lewis, L.Mayers M.G.Roy, S. C.Yura, .
Zimmer, M.
Evaluation
24 Daubenmire, A.J.Hammond, K. '
38, Hammond, K.-9 Lewis, L...
57 Nicholls, M.E.17 Yura, H.68. Zimmer, M.
THE PROBLMM-ORIalhD MEDICALRECORD (POMR)Introduction
563 Weed, L.L.
Background
80
650563-564
565
566567 .
568
Hurst, ?.W.'Mazur, W.P..
VWeed,L.L.Weed, L.L.Weed, L.L.
Weed, L.L.Weed,
r
1
1"
General Descriptions ,
Overall Descriptions, Concepts,Philosophy104 Aby, R.D.110 Alper, P.R.114 Appling, S.E.129 Bashook,.P.G.128 Bashook, P.G.129' Benage, J.F.75 Bjorn, J.C.141 Blake, T.M..147 Bonner, B.B.150 Bouchard, T.176 Carson, ?.,-179 . Castleman; B.185 Coles, E.C.194 cross, H.76 . Easton, R.E.211 Esley, E.222 Fleming, J.W.224 Fortuine, R.225 Eortuine, R:78 Friedman, H.H.
283 Hawkins,'C.80 Hurst, J.V.306 Hurst', J.W.321 Jervey*, A.J.340 , Langley, G.R.341 Lasts, P.M.358 .
364 McIntre, N.365 McIntyre, N.82 Mazur, WF.383390
Mazur, W.P.Meyer, T.
655 Miller, D.MODB64, R.A.
National LeagueNeelon,-F.A.Nellsoris G.E.
Otvay, W.435 Phillips, F.
Phillips, T.J.
Problem-Orienteblem-Oriented,..
Pro eMrOriented...Proble' riented...The Pro lem-Orientd....
85
87410
426
ts
438-446
447
414i
450
451
. '96-89-
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go
Jar
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-"e
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f
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.
4524530-
. 454
-4
475'486
493 ,
674516'517
-537
PRIMARY AUTHOR . rtEm # PRIMARY AUTHOR
The P;otlem-04entedf.ProbIem-Oriented...
The-ProblemOrientet...er.Probaem-Oriented...,
The.Problem-Orientee..Roger% A.I.'Sandlow,.L.
Schultz, J.R.Stiatmann, W.,C.
Taggart, M..
JUgert, MtTWin, E.J.Walken, H.K.Whlker.H.K.WO)ker, H.K.
Walker, H.K.Weed,
Weed, L.L.-
L.L.
Weed, .L. .
Weed, L.L.Weed,_L.L. ,
Yarnell, S.R.
I
if 94
554
5i5 5
55696* 0
"563
`%574 .
- 577
578581
564-
667
'Components
Data base
' 261 Grant, R.L.630 . t .Grant, R.L..
308 .Hurst, J:i.,
Problem iidt .
1T5 sCarr, M.L. .
230 Froom, J.
e353 - Longenecker, D.P.638 Mazur, W.P.640 Mazur, W. P .57 ,
6143 'MazUr, W.F.644 Mazur,.W.P..647 mdduriw.p.648 4RMMazur, W.F.
. . .
1 j
.
Initial plans
..642
f
.Mazur,
Progress notei`littd- flow sheets
207 Easton, R.E.
.2q9 Ellis,
277. Nm) hd KIX\
646 , zur, W.F. -
~ 492i. Schulman, J. 4
Adv.ntages, Disadvantages, ind..
'Controversy4
4
,
.11d125 , garclay,
133 Bernsteii,.R.A.at145 . Bogdondff,157 Buchan, R.F.
176 Carson: P.
178 Castlema, B.188 . Cobk, F.J.194 Cibss, H.D.197 Ti*oss,
.'213 Espenschaae, P.W.216 Feinstein, A.R.217 Feinstein, A.R.
222228. Friedberg, S.J.
238% ' G 11, M.
250' 'Gold3tinger, S.E.
251 GolHfinger, S.E.
283 Hawkins, C.
,298 Hood, J.N.
313Hurst,
.117 Hurst,319 Iasehberg, H.J.
322. John,
331 Kent, D.F.
I32' Kessnet,D.M.
. -\343 Levy, J.D.
.345 Lipkin, M.
'354 Lowe, G.R.voo.,356 Lytell, Ft
w.
4
ti
. k
TM # Y AUTHOR
357 Lytel, F.373 Margolis,- C.Z:651 / Mazur, W.P.,385 Me.ctical RecordA..386
391 ' Michael, M. , Jr.403 Nahem, L.H.405. National League,407f Ifeelon, h415
.428- . Palmer, T.S.662 . Tfifferling, J.H.437 D.F.439' Podell, R.N.445 The Poblem of the., ,
44/: Probl-em-Oriented...4147 PrabIem,0,-* ented'456 The Problem- Oriented...457 The Pi-oblem-Oriented....458 Problem-OH elated VS...465 Reed, D.E.500' Sheffield, R.501 .Sheldon, M.G.510 Snetzer, R.L:
.4 513 Strong, M.L.. 537
5i.7.
96
572574
589
Twin, E.J.Vickiry, T. E.
`Weed, L.L.
'W.eed," L.L.
Weed, L.L.Weed, L.L.
' InitiationMethods
' 75155
'212
3403
'310
662
663
443,93 ."
6021 100 -
Reports
Bjorn, J:C.Bryan, T.Esley, C.E.Hurst; J .W .
J.W.
PfAfferling, J.H.Pfifferling, J.H.
Problem-Oriented...Wakefield, J.S.Wogan, M.J..ZOog, S.
ITEM # PRIMARY ALPISOR
119 Asp, D. S .
127 Bashook , P. G .
.229 Froom, J.269 Green, 'H. )276 Hammitt, W.H.361 McCracken,381 ' Mazur, W.P:654 . Mazur, W.P. .
409 G.E.414 . Nevble,469 " Repdall , M,.
536 "'Tufo, H:Mc.
'r
494 Walker, H.X.
J
Applications
94 Walker, H.K.i
C
ApiPlications of the Prdblem-: .Oriented.Record
Specific FunctidnsAudit
.108
119
160
'203
.204
214
23:9
2232145
249
269,
270284
297304
312
33334
341
34-.4
346635
Alexander, E.L.Asp, D.S.
BoUthard, T-'Burger, C.S.Dixon,
Donabedian,Esterhay, R.J.Fedsel, W.J.Fletcher, R.H.Gilandas,Goldfingar; S:t.Green, H.Greene, R.Hawley, C.RolMas,HUrTt, J.W,Hurst, J.W.Kessner, D.A.Klonoff,Last, 'W.
' Liun, ,M7.W.
4iPP, M.McCann, E.
.
C-
I
4,
4
4
4
ITEM I
369. PIL
378J4.14-
'-. 432
_461
5A529535
540547
551/558
570573 At-
Tr9583585
595596
,6e910o-
-t
PRIMARY AUTHOR
Maeck , J . V .
Mathiesen ; K.M.
Newble J.14 -
Peck , R:L .
Putsch, R, ,R L
Tippett , J.
Tufo , H :M. , ,
Valentin, J.Vi'dkery , T.E..
Voytovich; A . 2,
W.-41iee , .R Br.
Weed, L. L .
Weed, L.L.Aed , L. Im
Weed, L ,
Weed ,. L
Weed, L.L.. Weiss , 'J.J.
Weiss, J.J.Yarnell, S . R
Zoog, S.
Educative and continuingeducation
105
107109112
123124128144158
178.
.19
21878
262
302 %v
307
309313..
3124
-352364\
Adamson ; T E
Albert, D . A :
Alexander E LAndrus, L HBegby, , G. C .
Barbaccia, J.C.Bas hook , P G
T. -
c, ICaplan, L .
CaAlb6an , B.
Cross, g. D
FelixeFriedman, H.
Grant , R .
Hursto J VHurst, .41.W .
Hurs£ , . W.
'Burst, J.W.Hurit , J .;.[. '
Lloyd-; G.
McIntyre,. Ns
# PRIMARY .AUTOR. ,
373 Margolis, C . Z .
374 Margolis, C . Z .
Mason, R.' .
Nelson , *g.E.
1423 o Connor , F .J .
1444 Problem-Oriented. : .
1463 Rana ,' B.
512 , Steuart,'
530 Tolby ," B.g.
533, Tompkins ; R.K.
538 Valberg, L.S. ' .
564. Weed, L.L.
565 Weed,. L.L.
572 yeed , .L
576 Weed, L . L .
,58Q Sft-ed ; L L
e41.
. , .
r.
Algorithms Etad physicians'
assistants
138 Bjorn, J.
156 Brydon , J:
161 Burger, C . S .
272 Greenfield, S! 295' Holland, R.R.
326 Kaplan , A . D.
K6mardff648 14azur,, W. P .
421 .Nuckg1ls, J. 0
)46.6' Reed, D.E..-
472- r, Bodes; A509 t o, Sox , 'H. C
519 Taylor, J.E. %
526 - ThSrlor, E.
. 521. Taylof; J . .
.531 Tompkins, -R . K.
549 Yoltman, J.D.
Specific Settings and ServicesPrivaiefuractice
111 Anderson, T .
139\ Bjorn, J.C.13 Bran dij 8 , J F
159 BurchelL, K.184 Clark, E.M.'
V
.
ITEM/ PRIMARY* AUTHOR
.
195 ,. CrosaZrb. ,_....t...
196 Cross, E.D.256 'Grace, M.T.
289 Heitnon, P.D.325 * -Kptor,.T.G.:330 Kent', D.F.
423. Page, D.C. t
*462 Waal, R'. E .
1.99 Shay, S.W. '506 -) ...i1.1..-stein, G.
518 Tait, I.
5314 Tudor , .
543 Vash, G.T Walker, :..ax.
560 mik War'ren,, y..II.. Ilr .
Athulatory care
113 61 y, B.' -117 krmstrong,275 Hall,'W.D.311,, ..Hurst,
339 Lathert, R.Pm
A1414 Perry, A.
507 Szait-h,
91 Vickery, D.M.
599 Widmer, R.B.
Rehabilitation
183 {? Ckiatte,191* Crawford,201 /' Dinsdale, S.M.202 Dinsdale, o.M.-2D8 Ecpteen h, J.L. m
624 'Feitelberg, S.B.253 Golodetz,255 Grabois; M.257 Granger,*C.Y.'
299 Ho".ft, WH324' 'Kane,.R.L.325 / Kantor TJG.392 N.ilhous, R.L.
393 Milhotzs, R.L.429 Pankratz I.
.468. Reinstein,1:
1
4
ITEM/ PRIMARY AUTHOR
psychiatry. and nsychoAcialtasnects
thrams, R.S.Barchiesi,Bostock, T.W.-Boza, R.A. ,
Carothers, R.A.Carothers; k.A..Deming, B.Donaldson, F.W.Draper, W.Encow, A.J.Fay, H.J.
Gaviria? B.Gil'andaS, A.J,
Gllandas, AO.Gilandas, A.J:Grant,
'Grant R.F.Grant,
Grant, elt...
GrPant,
Grant,. RIL.
Grant,Grunt, Rit.Greenlea4 1 W.
Harvey; 2r.
-Hawley,
Hayes -R 7. .
Hayes- 4, F:eHayes- , F.
Hirsch R.G.
Rood, JKlonoir
10*614
149'
152
619r,620
199'205
ZO6210..215
2,27%
240243 ,
2,2,4
245
258
759
260
.261
263.264
630631
273279,
-284285
286287*
293298334
346,348
350-634 .
554
. 366
36736882
381
383-,
638-
641
.i0
I
T-4PP,Lipsi L.R.
Liskow .1.
ListoLori , J.H.
LoudMc t, R.S.Mc ght; R.S.
P.D. ,
r, W.P. *I
rippeW.N
ur, W."W.P.
zur, W.P.
A
.
ITEM i PRIMARY AUTHOR ,
645 Mazur, W:P.4
1:-647 -Mazur; W.P.
S 648 Mazur, K.P.652 Mazur, W.P.653 'Mazur, W.P.654 MaFizr,
391t, 1.11.1er, E.
39E Miller, S.I.M, ern, T.
420 e11o; J.R.664 .1 Pfifferling, J.H.459 Puller, M.L.464 f Rashidi, B.473 Richert, R.'478 Rpthstein, E:481" G.E. --
88 Ryback, R.S. "483 'Ryback,' R.S.489 Scales, J.498 ' Sehdev,508 L.C.
511 Spitzer, R.L.528 Thorne, .O.529 TipRett, g.532 C.B.
Vickar, G.M.544
11=6 Vickers, R.600 Williams, D.E.
<T7
Acute' care and coronary care
10S
237296
327.
. 360
503504
552
405
AbAms, J.S.Gardner; L.B.Holloway, R.M.Kaufman, T.McColl, I.Silverman, w.E.Silverman, M.E.Waisbren, B.A.Worthley, L.I.
pediatrics, .schoolheal" and college health
.144, ''Sjorn,J.e;162 Burger, C.S.
10.
ITEM I PRIMARY AUTHOR
) o'182 Christie, R.W.239 Gaskins, J.R.280 Haswell, J.-281 Haswell, J. iS
294.
311 Hursiti, J.W.
351369 eck, J.V.404 Hareng, A.
423 Newberger, E.H.485 Salta, E.W.496 Scott, S.R.561 Ways, P.O.
Other medical spetialty areas
169 Campbell, H.J?181 Christie, Eiji.191 Crawfo2d, G.B.265 Gravahls, M.B.266 Goevicnis, M.B.316 Hurst, J.W.424 O'Connor, F.J.658 O'Connor, F.J.478 Rothstein, E.487 Savatt, L.A.
594 Weinsteino G.N.636 Wright; R.K.
Dentistry., pharmacology,
nutrition, and other nonmediceiareas'
168 4orgsdorf, L.R.165 Burri11; G,C.
180, Chappelle, M.L.624 Feitelberg, S.B.46 Gilroy., G.
318 iingber,-J.S.323 Kane, R.A7355 .Lyris, F.M.
gelson, G.442 Pott L.R.
Rat ff, J.476 , Rogers, T.V.522 Teeter,'l).S.
.1
I
533550
559
--ArIY AMOR IT I PRIMARY AMOR
A.F.Voyt. ch, A.E.
Waiterk F.M.
Studies and Surveys
_ 105
613116
119130
.1g9'
20223
Jek29'.247
276315
320
3503733754044-o81414
468 -4733672
49549705
14
51541
C
Adamson, T.E.Amer MBAAranda',' M.J.
Asp,,D.S.Bentsen, B.G.
H.J.
.Christie, R.W.Dixon, R.H.Fletcher, R.H.Frboa,.J.Gledhill, V.Hahmett,'Hurst, J.W.
Iverson, N.T.-Liston, E.H.
alas, C.Z.Margolis, C.Z.Naraag, A.. .
Neelon, F.A.Newhle, D.I.
Reinstein; L.Richert, R.Richert,'R.Scott, H.M.Seawright, L..C.
Sirborg, D.W.Switz,
Svitz, 5.m.Van Egmoad, J.Vickar,t G.
Wogan, M.J.
Modifications
Aronson,'
126 Barry, J.M.136 'Bira, W.F.215 Fa.Vi H.247 Gledhill, V.248 Gledhill, V.
't:
290 Herta,344 Linn, M.354 Lowe;
3T7' - Mathe'r, B.
.636 MEW, P.637- May, P _
.Mazur, W . P.383 Mazur, W.P.
639 Mazurs. 642 Mazur, K.P.645 Mazur, W.P.649 Mazur, W.P.
, 358 Meldman, M.J.471 Renner, J.H. .
484 St.- John, D.485 Saitz, E.W.
552 a Waisbren, B.A.
597" Westran, W.C.
598- Whyte,.F.605 " Worthley% L.
MO'
MannFOR and Teaching Guides
137618623
,625.
6
63
29
659660661 .
665
666668669-676
.677
679
Birk, P.
Brown,AG.C..
Eastern StateP.
G visa, 'B.
nch,
Hdab,'J.0,How to Use...Medical Collegs:-..
Pediatric Group...
4 The Problei-Oriented...2Problem-Oriented...
PROMIS Adult...PittsburghbV.A.H.-Systemedies...Watfhingtoa, D.C,Wattersod,,D.J.
Hospital
4kIRSING,AND THE *im ,:-oraiaTEDRECORDConcepts, Philosophy, andDescriptionsBooks and Monographs
TO Atwood, J.
-102-95- Pa,
ITEM I is
736262/.628
8385
9860
95
99
Artic/es
120-121
163164
167190
g233234
235292300 _
'305
337'.
370
379397'405
436
490
603.6o8
,ARY Ati2 0 ITEM I PRIMARY AUTHOR
Berri, R.Gene, D.Gene; D.Gene, D.'
Meldman, M.National League...National League...Vaughan-Wrobel, B.Walter, J.B.Woolley, F.R.
Atvood, J.Atwood, J.
4ura, M.A.Burnett.,
Cads , N.
Crabtree, M.K.Creighton, H.Gene, D.
Gene, D.Gene, D.
Gene, 10Hill, P.A.Howard, F.
Hurst,_J.W.LamNert, K.Nal]ky, J.L.Matthis, B.Mitchell, P.H.National LeaguePhillips, D.F.Schell, P.L. t
Woody, M:Yarnell, S.R.
InitiationMethods'
626621628
362?
379406
.Gene i D.
Gene, D.
Ganes D..
McGriff; E.Matthid, E.
National ,League...
527 Thompson.
92 ByrliTigton'
Reports'
10312214319825.4
291
. 300328333,
425
43.1
474
523524 .
526542,
92
60361.1
Abruzzese, R.S.Bacon, L.F., -
Blooa,'J.
Davis, B.C.Good,'S.Hill, A.HoWard, F.
Kelly; W.E.Kinney, L.
O'Grady, T.R.Payne,, S.
Robinson, A.M.Thome, D. -
Thompson, S.P.ThOmpson, S.P.Van Meter, M.U.TEA, BurlingtonWoody,.M.Young, L.A.
ApplicationsFunctions
Audit
119 Asp, D.S.131 Bernt, R.20 Bloch;,
1116 Bonkovskt, M.L.622 7 Davis, E.627 Gene, D4278 Hartmads M. ___fr.
334 Kionoff, H.480 - Rubin, C.490 40 Scheil, P.L.503 16 SilverMan, M.'E.504 Silverman, M.E.583 Weed, L.L.604 Woolley, P.R.
103..9fr
4.
/
.
,
ITEKI PRIMARY AUTHOR ITE4 if PRIMARY AUTHOR
Educationi.continuing education
124 Barbaccia,174 Carey, I.282 Eaten, P.162 McGriff, E.392 Mitchell, P.R.441. Popfel, E.S.
Interdisciplinary communication
Atwood, J.
Lambert:K.National LeagueRobinson, A.M.Thompson, S.P.
Yarnall, S.R.Zoog, S.
Settings and ServicesPublic Health
115 Aradine:'C.146 Bpnkowsky, M.L.174 Carey, I.177 Caserta, J.E.622 D s, E.220 Feld, F.W.254 Good, V.M.328' Kelly, M.E.329 K 2ly,, M.E. ,
379 Matthis, E.86 National League...524 Thompson, SI,P.525 Thompson, S.P.526 ,./Thompson, S.P..527 Thompson, S.P.
92 VNA, Burl548 VNA, Burlington621 .Young, L.
t
t ,
Ambulatory care settings
.156
342479
Brydod, J.
Leonard, P.
Rothwell, M.G.
_519-52(t
Taylor, J.;Taylor, J.
,Rehabilitation settings
132 BrP.1 R.621 Conti, R.M.433 Pepper; G.A.494:. 'Schwab, M.
I.
,.- Psychiatric settings
623 Eastern State Hospital241 Gerken,. B.284 , Hawley, C.301 Huff, L.H,
General hospital settings
166 Cadtus, M.G.627- 'Gene, D.333 Kinney, L.
Acute care and corgnary,caresettinm.
135 Best, R.431 Payne; S.50a504 Silverman,. M.E.
Studies .,/
119134 Bertucci, U.142 Bloom, J.226 Foss, B.371 - Mantle, D.D.397 Mitchell, P.H.398 Mitchell, P.R.616 Mooney, S. M.M.430 Parker, 2.479 Rothwell,M.G.
,'1
ITEM I PRIMARY 'AU171:83R,
488 ffavett,
523 Thom, .D.'
Manuals, Worlbooks, and Forms
615 BonkoWsky,:M.L.
177. *Caserta, J. .
.623 Xattern State Hospital'
221 Fie,Ord, F.W.
627 Gane, D.
628 Gene p..
85. National League...
86 National Le
627 Thompson, S.P.9Q Vaughan -Wrobel, B.
677 Veterans' Admin.
92
548
616
617cImn vations and Adaptations,
VNA, BurlingtonVNA, 'ffurtington
Brentwood, V.A.H.Brentwood, V.A.H.
142 - Bloom, J.
198 Davit, B.C.
484 St. Johni- D.
.,
Nursing 1::roCess and Problem-
Oriented Appro66hes N
1§ Abdellah, F.G:'.103 Abruizese, R.S.
106' ' Ahiles, A.
72 Becknell, E.P.
143 Bloom, J.
3 Et:II/fling, M.H.
627 Gane, D.
81 Larkin, P.D.-.
8 Lesnick, M.J.
359 McClosky, J.C.
370. Malloy, J.L.
379 Matthis, E.J.350 Matthis, E.J.
397 Mitdhell, P.,'
40Y )t&zek,'R.
417 Niland, M.B.418 ' ,-Nolan, M.G.
p
ITER'# PRIMARY AUTHOR
422
488 Si4ett, L.
523 Thorns, D.
90 Vaughan-Wrobel,.B.C.677., Veterans' Admin.,
. .
THE COMPUTERIZED 'PROBLEM-ORIENTED RECORD.-Background
200 Dietrich, P.
387 .Meldman, M.J.
h12 Nelson,A.E.562 Walton, P.L96 Weed, L.L.
Weed, L.L.Weed, L.L.>Weed, L.L.,Weed, L.L.
Weed,
564
566 '
567
591592
678 Weed,
Concepts and PhilosophyGeneral
4
171 Cantrill,
172 Carrtrill, S.V.
187 Conway; 14.13%,
3,89 Cordole, F.205 Donaldson,
252 Goldstein:, F.
267 Graves, S.
g68 prates, S.286 Hayes-Roth, F.
396 Mishelevid4, D.
419 Not as ,s Scientist
467 Reid, f4. H.
93 Wakefield' J.S.
96 Weed, -L.L.
97 Weed; L.L.
571 Weed,. L.L..
582 Weed, LA,.
589 ,Need,. L.L.
591 L.L.--
1-.592/ 'led, L.L.,.680 W ad, L.L.
610 Young,
1O5
of
ITEM / PRIMARY AUTHOR' I
Confidentiality
*482 Rumsey, J.M.586 Weed, L.L.601 Williams, J.I.
/ -Empathy
242 Gertzog, J.384 \ Mazur, Wt.P:416. ,Nies, A.587 .. -Weed, L.L.:
Descriptions
General
172231 .
236288399436
470493678'
97588592
Components
Data' base .4171 Qantrill S.
231 Gene, D.80 Hurst
336 Krismer, J.R.399 . Mittler, t.S.668 PROMIS460 Putsch, R:569 Weed, IL:
Cantrill, S.V.Gane, D:Gane, D.
Health Data System...Mittler, B.S.Phillips, D.F.Renrier, J. H, .
Schultz, J.R.-Walton, P.L.Weed, L.LWeed, L.L.Weed, t .L.,
Plans
37:
4
Nelson, "G.*
17E24 I PRIMARY AUTHOR
Prc.`igress notes
98 Weed, L.L.
Initiation andAceptance
205242562
'Donaldson, F.W:Gertzog, J.Weed, L.L.
t
Applications .
Audit and Education0
186 Conway, M.E.5Q2 Silberman, L.. 97 Weed, L.
sSettinfs
. 154
189
200. 274.
288; 491
6.75
539
78553
. 6
.
and Services
4
sBrIlwn, D.
Cordole, F.Dietrich, P.Grpsmezr, J.H.Health DEi.t.a System.
Schmitt, E.Summary Report:"..Valbbna C .
Wakefield,.Walton, P.
Studies ;
1.
154." Brown,1/4
D.271 Creates, R .A.274 Grossman, J-:11.336 Krieiner, J.R a389 Mellner'q C.491 Schmidt,, E
4.
-99-
A
.19
'44
1 11" ITEM # PRIMARY AUTHOR
4.-
ITEM # PRIMARY AUTHOR
\.NURSING AND THE COMPUTERIZEDPROBLEM=ORIENTED RECORD .
. Introduction
673 . Saba, 17,
Experience
231 Gene, D.236, Gene, D.627 Gene, D.
I 4
is
4,
.
I
r"
107
1>
.
, .
4
p
NURSING PROCESS
Books and Monagraphi
.
14 Abdellah,Jay,G.; Martin, Almeda; Se,lancl,. Irene; and*Mlatnete'y,Ruth. Patient'Centered Approaches to,Nursing, New york:
.
1
The MacMillian Company, 1960." ,,,
2. Bonney, Virginia, R.N.', M.A.'4 and Rothberg, June, R.N"At.A. %Nursing Diagnosis and Therapy: An.Instrument foilEvaluar.tion and Measurement (pub.-no. 20-1085). Nei York: ..--
Nptional League for'NurSilag, ,1963. -
3. Browning, Mary H.-, R.N., compiler; and Minehan, PELula L., R.N., Ni. consultant. The Nursing Process in Practice (Contemporary
Nursing Series). New York: The American JournaloofNursing Cagtpany, 1974. " ) .r
.
i.. .
4. Buckley, Walter, ed. 'Modern Systems Research for the BehavioralScientist. Chicago, I1J.: Aldine Publishing Company, 1968.
5. Freemstl, Ruth B., Ra., EdiD. Community Health Nursing Practice.PliThdelphia, 131..: -W. R. Saundeis Company, 1970.
. '.,-
t , . '
6., Hamar., Bertha, an4 Henderson, V. A. Textbooksof the p#nciples. and Practices /of Nursing (4th rev. ed.). 'New York: The
MacMillan CoMpany,1939. : \ . ,.
.
,a 7 Jensen, D. M. Student Handbook on Nursing Case Studies. New-alit.York: TheMacMillan Company, 1929. /
1!,,
4. .
8. ick, M. a. and Anderson, B. E.. Nursing Practice and the Law-42nd-4.2nd ed-r-:...-Philadelphia, Pfi-.`-t--1:7-.--B-.-- Lippinciatt-Conaiany,---1962. ' .=
. 't
,
Lewis, Lucile: Planning Patient Care. Dubuque, Iowa:..., Wm. C. Brown Company, 1970.C, , ,
Little, DoloikS E R.N., M.N.; and CaTnevaLicDorisj,lt.N.,M.N. Nursing Care Planning. Philadelphia,A.: J'. B.-LippinOrTT Company, 1969. ,
s
M4er, Robert F. Preparing Instructional Objectjves.Alto, Calif.: Fearon Publishqrs, 1962.
4,
IP
Palo
t,
'
...
12." Mayers, Marlene Glover, R.N., M.S: A SystematicApproach to the. Nursing Care Plan. New York:. Appleton- Century -Cr fts, .
EducatiOnal Div.,'Meredith Corporation, 1572.,..,- . 4 . t
13. National League+ for Nursing Education. A Curriculum Gu de, for,Schools of Nursfng (2nd rev.,ed.): 1New York: .NationalLeague for Nursing1937. ,t, .
..
- v
14. Nutting, Miry Adelaide.' A Sound Economic Basis for Schools ofNursing. .New York:' G..P: Putnam's Sons) 1926;
15. Ujhely, GetrudB. Determinants of the Blirse-Patient-Relatiopship.'New York: Ipringer Publishing Comiany, Inc., 1968.
16. Yura, Helen, and Walsh, Mary B. The NursiPlanning, ImRlementIng, Evaluating (1st,Appleton-Century-Crofts, 1967.
Process Asgessidd.). .Nev York:
. 'The Nursing_Process: Assessing,
4
e
Planning, Implementingk,\ a1uat1ng (2nd ed.)., New York:Atpleton-Century7Croft'a, 1913.
V
Articles i-.,,
. -.-`......
.
18.''Abdcllah, Fay G.. "Methods of Identif*ng Covert cts ofNursing Problems. Nursing Research,"6 (1): 23,June 1951. ,,,:.
. . .-
,
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. "Our EtperieneesUsing '.roblem Oriented RtCords." Resident and StaffPhysician, 18 (6): 36-39, 43-46, June 1972. ,
44
-415
$
I
597. Westman, Wesley C. "A Solid Front: Unity Timing Goal OrientedCounseling Break Drug Addiction Cycle." Journal ofRehabilitation, 15-17, May-June 1974.
598. Whyte, F.; Macneil, A. R.; and Nicholson, D. "TuberculosisAbscess in the Chest Wall 25 Tears After PneumoneetomY,Case Report to Illustrate a Slight Modification of theProblem- Oriented Medical Record." Nova Scotia Medical'Bulletin, 51 (4): 86, August 1972.
599. Widmer, R. B. "Problem Oriented Medical Records in AmbulatoryPatient Care." Journal of the Arkansas Medical Society,71: 113-124,,AApst 1974.
60a. Williams, D. H.; Jacobs, 6.; Debski, A.; and Revere, M."Introducing the Problem-Oriented Record on a Psychiatric_Inpatient Unit." Hospital Coihmunity Psychiatry, 25 (1):25-28, January 1974.
601. Williams, J. I. "Privacy and Health Care." 'Canadian Journalof Public.Health, 62: 4 95, November-December 1971.
662. Wogan,..Mary Joan, R.R.L. "AM RA Survey Shows Enthusiasm Is Keyto Success With POMR." Medical Record News, b2 (5): 57-60, October ;.971.
603. Woody, Mary, and Mallisgn, Mary. "The Problem-Oriented SystemFor:,Patient-Centered Care." American Journal of Nursing,73: 1168-1175, July 1973.
AK604. Woolleyi F. R., and Kane, R. L. "Telling It I4ke It Is
Through Problemprientation." Nursing Care, 9 (6): 25-27,June 1976,
605. Worthley, L. I. "A System-Structured Medical Record for_Intensive Care Patient Documentation." Critical CareMedicine, 3 (5): 188-191, September-October 1975.
606, Wright, Ronald K. "The Problem Oriented Autopsy," in Walker,H. K., Hurst, J. W., and Woody, M. E., op. cit., 1973,
k pp. 432-440 (item no. 94).
607. Yarnall, Stephen R. "The Problem-Orianted.Approach--A Sine QuoNon for Audit," in Zoogi S., and YarnalL S., a. cit., 1976,pp. 161 -165 (item no. 100).
608. Yarnall, Stephen R., M.D.; and Icerson, Nichol T.t"Structured,Ptoblem-Oriented Recgrds in Office Practice.' Northwest .Medicine, 70: 166-167, March 1971.
4
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157
609. YarnallStephen R., M.D.; and Atwood, Judith, M.N. ,"ProblemOriented Practice for Nurses and Physicians." Nursing,Clinics of North America, 9 (2): 215-228, June 1974.
,1Young, D. W. "Organization of Information Into Displays."
CoMputers and Biomedical Research, 5: 148-155, April 1972.
611. Young, 4disLASystem,"op. cit.
612. Yura, Helen..
Nursing,
).s\.......eno. 86
. "Agency Experience With the Probleth-Oriented
in National League for Nursing, PO. No. 21-1522,, 1974, pp. 134-148 (item no. 86).
"The.Nursing Process," in National League forPub. No. 21-1522, op. cit., 1974, pp. 5-13 (item)
Unpublished and Other Materials
613. American Medical Record Association. "Evaluation of UtilityProblemlbriented Medical Records: (Cost Reimbursement)Proceedings and Results of the Charter Advisory CommitteeMeeting." ecember 3, 1975, Chicago, Ill., AmericanMedical Record Association, February 4, 1976.
614. Barchiesi, A. "aperiences and Reflections About the POMR -
in Psychiatry)." veterans Administration HosiAtallrAngusta,-Georgia.
4P615; Bonkovsky, Marilyn L.; Field, Frances W.; Schorf, Marie; and
Tompkins, Richard K. "The Problem-Oriented Health CareRecord: &Manual of Instruction or Community Agencies."Dartmouth PROMIS Laboratory, Dartmouth Medical School, ',,,
Department of Medicine, 1973
616. Brentwood Veterans Administration Hospital. ."An Introductionto the. Quantified- Problem /Goal Oriented Medical Record(Q-P/GOMR)." Brentwood Veterans Administration Hospital, -Program Evaluation Service, Los Angeles, Calif., August1975
617. . "An Introductionto the Quantified-Problem/Goal Oriented Medical Record(Q-P/GOMR)." Brentwood Veterans Adnlifiistration Hospital,
Program Evaluation Sefvice, Los Angdles, Calif., March 1976.'
61B. Brqvn, Gorge C., "PakiR With Revisions." Veterans Administra-tion Hospital, Battle Creek, Mich. 49016.
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. 158
at
619. Carothers, Richard A., Ph.D. "Our Understanding of the POMR,
62o..
How It Works in Day-to-Day Treatment Planning, TheDifficultlei Which Arise in Initiating Such a Program andj .
the Directio'n in Which Our Day Hospital Program is Heading,"Veterans Administration Hospital, Day Hospital, Oklahoma.City, Okla. 73194.
. "Problem Oriented Treatmentning in a Day Hospital Program." Paper presented at t4th annual meeting of the,Southvest Partial HospiializatiConference, Dallas, Thx., November 16, 1974.
622. Conti, Roberta M., R.R., M.S. "Annual,. Report." MarylandRehabilitation Center, Department of Nursing, AnnualReport, July 1, 1974 to July 1, 1975.
622. Davis, Elizabeth. , "Eyaluating Accountability and Audit."National League fore Nursing Biennial Convention, Anaheim,Calif., April 25, 1977.
623. Eastern State Hospital Procedure Mantel "Problem OrientedMedical Record (POMR)." Eastern State Hospital, MedicalLake, Wash., June1973.
624. Feitelberg, Samuel B., R.P.T., M.A. "The Problem OrientedRecdrd System in Physical Therapy." Department ofPhysical Therapy, University of Vermont, Burlington, Vt.,September 1975. r
625. French, Perrin, M.D. "Revised POMR Manual." Vetei-ans Adminis-tration Hospital, Palo Alto, Calif.
626. Gene, Donna. dbookPROMIS Laboratory,1972.
627. . "Nursing:Center Hospital ofVt., July 1974.
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I
The Problem Oriented yay." MedicalVermont, Inservice Dept., Burlington,
628. . "Understanding the Problem-Oriented Record: ABook of Exercises." PROMIS Laboratory, University ofVermont, January 1975.
629. Gavira, Benardo, and Pratt, Donald F. ."POMR in Psychiatry;Instruction Manual for Problem-Oriented Record Keeping inPs chiatric Services." Veterans Administration Hospital,Alb, N. Y., 1973. 7
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159 4
. -
630. Grant, Richard L.,M.D:NData Base.Collectiod and ProblemFormulation in Psychosocial,Care." University of Vermont,College of Medicine, Department of Psychiatry, Burlington,
-
-Vt. --
631. ____ .. "Cmarehensive Health Care Records,
Behavibr ed Therapies and the Problem- Oriented Record."Paper pre ed for the seventh annual meeting of theAssociati for Advancement of Behavior Therapy, Miami Bdach,Fla., Deebember 7-9, 1973.
632. "Guidelines for Utilizing the POW Nanual.". Veterans Administra-tion -Hospital, Lyons, N. J.
633. Hess, Joseph; Stern, Daniel; and Henderson, H. Ridhard. "TheProblem-Oriented Record: __An Orientation Manual." Wayne'.State University-, School of Medicine, Detroit, Mich., 1973.
634. LoAgan,.Dr. J. H. "Manual - Describing a PONE System Which t
. Includes Flow Sheets for Specific Medical Situations and --An All-Purpose Flow Sheet for Psychiatric Problems.".
Veterans Administration Hospital, Lyons, H. J.
635. McCann, David, M.D. "POMR,System - Record Audit Form and ServiceAudit Form." Veterans Administration Hospital, Salt LakeCity, Utah. '-'
636. May, Phillip R. A. "Problem-Oriented Midical Records Development."Veterans Administration Hospital, Brentwood, Los Angeles,Calif.
637.- May,Phillip; Kohler Adam; Messick, Janice; Smith, Dolores;and Archer, Claude. "Quantification in the Problem/GoalOriented Medical Record.(Q-P/GOMR)," in "An'Introduction'to the Quantified-Problem/Goal Oriented Medical Record'4Q-P/GOMR). Brentwood, Veterans Administration Hospital,Los Angeles, Calif., March'1976.
638. Mazur, W. P. "In Search of a Better-Tool: Plans for Re-Designing the Problem List."
639. . "Procedure for Using the Asset List."Osavatomie State Hospital, Osavatomie, Kans.
640. . -"Answers to the Questions: What Is a Problemand What Is Not a Problem?" Osawatomie State Hospital,Osavatomie, Kans., 1972.
641. .. "Coffee-Break Questillik.." Osavatomie StateHospital, Osavatomie, Kans., Febtuary 17, 1972.
231-II1 0 II --.I
-143-1 A60'
I
642. Mazur, W. P. "Doctor's Plans in POMRSystem; Item:, PatiatEducation." Osavatomie Statellospital, Osavatomie, Kans.,May 1972.
643. . "PfMR System. Definition of the Terms 'PiOblem'and 'Problem List'." Osavatomie State Hospital, osawatOmie,Kans.., 1972.
644. . "Problem List." Osavatomie itate Hospital,Osavatomie, Kans., 1972.,
--645. . "Problem Oriented Rec tomie State
Hospital, Osavatomie, Kans.; February 173)1972.
646. . "Thoughts on Soaping of Progress Notes." Osava=tomie State Hospital, Osavatomie,
647. . "Use of the PrObldm-Sorti Work-Sheet," anillustrative case. Osavatomie S ate Hospital, Osavatomie,Kans., 1972.
648. . "Weed Without Tears or Twelve Easy Steps to Makea Complete Problem List." Osavatomie State Hospital,Osavatomie, Kans., 1972.
649 . "A Care for More Than One Problem List." Osava-tomie State Hospital, Osavatomie, Kans., 1973.
650. . "Historical Bac.:. lid of the Weed System."Osavatomie State Hospi al, awatomie, Kans., 1973.
651. . "Seven Reasons for Ad e Weed System."Osavatomie State Hospital, Osa e, ., 1973.
..652. . "Structure and Principles of the Problem-OrientedMedical Record Systems in Use at the Osavatomie StateHospital in 1973." Osavatomie State HOspiia2, Osavatomie,Kanp., 1973.
. s 653. 4 . "Weed System Discussed With Fellow Psychiatrists."Osawatomit State Hospital, Osawatomiq, Kans., 1973. ,
4,. 654. . "Problem-Oriented System: The Weed Method ofMedical Record Keeping and Its Use in a PsychiatricHospital.," Prepared for distribution at th;127th annualmeeting, American Psychiatric Association,. Detroit; Mich.,
,... May 5-7, 1974..? "%,
'I
.
`,,,
:h.
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7-- 161
655. Miller, David. "The Problem-Oriented Medical Record: Adminis-trative Implications," in Proceedings of the FifteenthAnnual Symposium on Hospital Affairs, May 1973. Conductedby the Graduate Program in Hospital Administration andCenter for Health Administration Studies, Graduate Schoolof Business, University of Chicago.
656. Mooney, Sister Mary Margaret. "A Comparative Study of Nurses'Recording of Analgesic Therapy.: Case Western ReserveUniveisity,. Cleveland, Ohio, May. 1972.
657. "Nursing Service PROMIS Manual." Pensacola.Naval Hospitil,Fla., 1972.
658. O'Connor, krancis 1. "Form for Oncology (Radiotherapy) Consul-tation." General Hospital, Augusta, Maine.
4 Palo Alto Veterans Administration Hospital. "How to Use the ,Problem Oriented Medical Record at the Menlo Park Division."Palo Alto, Calif.
660. Pediatric Group Services. "Self Teaching Guide to theyrobiem-Oriented Medical Record." _Medical College of Pennsylvahia
-Pediatric Group Services.
661. "Pediatric Problem- Oriented Record." Mddical College ofpennsylvania,, 1972.,
662. Pfifferling, John Henry. "Outline Text for POMR Discussion atthe APA Task Force, Washington, October 17, 1974.
663.p
"The Problem-Oriented Medical RecordSystem Recordrand Revitalization." 'Dissertation,-Pennsylvania State Unliersity, Universlity Park, Pa:, 1975.
664. Pfifferlihg, John Henry, and Pfifferling, Vera, compilers; andBerg, Karen, consultant. "The Problem-Oriented MedicalRecord." (a source bibliography) Togus, Maine, August 1974.
665. Pittsburg Veterans Administration Hospital. 'Manual on _the
ProblettOriented Medl.cal Record." Pittsburg Veterans4dministration Hospital,-a., 1972.
666. ''The Problem-Oriehted Healtb'Care Record: 4, Manual of Instructionfor CoMmunity Agencies." Dartmouth PROMIS Laboratory,Dartmouth Medical School, Department of Nedicine, Dartiouth,N. H., 1973.
667. "Problem Oriented Medical Record Developments." _Veterans Adminis-tration'Hospital, Brentwood, Los Angeles,, Calif., March 1974tfirougfi March 1976 (discontinued).
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668. "Problem - Oriented Medical Record Procedural Manual." North.Dakota State Hospital, 1972.
669. Professional Service Chiefs. "A Simplified, Nine Element POMRData BasemForm." Professional Service Chiefs, VeteransAdminAstratio spital, Brentwood, Los Angeles,
670. PROMIS II. "Adult Medical Ristory Questionnaire for ProfileM-Oriented Practices." Systemedics, Inc., Princeton, N.J.,1970.4
671. Ratcliff, Jane. "The Problem-Oriented App to Physical.Therapy Care, Part I: The Problgm-Oiefited Medical System,and Part II: ,The Physical.-Therapy Problem-Oriented SONote." Master's Thesis, Medical College of Virginia,
ZEP
Virginia Commonwealth University, 1974.
672. Richert, Ron. "Survey of the Problem-Oriented Record inCanadian Psychiatric Settings." Brandon Mental HeafithCentre,Brandon, Manitoba. s
673. Saba, Virginia, and Levine, Eugene. "Management Informationstems for Public Health/Community Health Agencies: An
dine of the Objectives, Basic Types, Factors at Play,and State of the _Art." Paper for .wesentation at the annualmeeting of the American Public.Health Association, MiamiBeach, Fla., October 18-21, 1976.
674. StratMann, William C. "Implications for the Implementation ofPROMIS A Bibliqgraphical.Review." Prepared in accordwith. the requirements of Health Services Resources Adminis-
A/' tration,Contract HRA 230-0204, March 1976.
;--------.(175. "Summary 'Report: Health Care Technology Systems." National
Technical Information Service,.U. S. Depatent of Commerce,. 5285.rort_Royal Road, Springfield, Va. 221 1, June 1969.
_--V.
676- "Systemedics Problem Oriented Me4cal Regard System." Systemedics,Inc., Princeton Air Researdfi Park, 2..kinc ton, N.J., 1972:7
-
d/e2677. Veterans Administration. "Interim Guideli es: Problem OrietAid
Medical Record (POMR)." Nursing.Service, Department ofMedicine and Surgery, Veterans Administration, Washington,D.C.
J I0
71567163
678. Walton, Peter B., M.D. "Background Reaaing Material:, TheProblem-Oriented Medical-Informatibn System (PROMIS) "'Division of Health Cafe Information Systems and TechnolbBureau qf Health Services Research, Health ServicesAdministration, Rockville, Md., December 1,1973.
679. Watterson, D. J. "Problem Oriented Record Manual." HealthSciences.Centre Hospital, University of,British Columbia4.rancpuver,'British ColuMbia, Canada, 1974. -
680. Weed, Lawrence L. "Automation of a Problem.: iented. Medical'Record." (Grant Application) August Y.;..4.9,73.
J
-154 6 4
4
_INDEX OF Am
10.
AUTHOR ITEM
Abdellah,111P.G.
AbdellabGAbrams, J.S.Abrams, K.S.'Abruzzese, R.S.Aby,.R.D.
, Adamson, T.E.
`Ahles,416.
Albert, D.A.A Alexandds; E.L.Alexander, E.L.Alper, B.R.Alvis, J.* '(1
Americaxi4dical Record s.. 1Association
Nendersap,Andersbn, T.P.Anders8E, T.Andrus, L.H.Ansley, B.
Appling, S.E.Aradine, C.Aranda, J.M.Archer, C.*Armstrong, J..ArOnsollM.D.Asp,- prs.
411/
$
Atkins, C.*Atwood,' J.
. _Atwood, 1. .
Atwood, J.
Atwood,'..7,
Atwood, J.!
Backer, B.A.*Bacon. L.F.Bagby, G.C.Barbaccia, J.C.
.
104
105106
107/108 If199
.**
1102CLO
-613 C.)
8
1111201112
113
I
114, .".
"115. 116,
637.117118,
119
27970
120.
: 121
398
81122123124
.
.*SecondaryAtthor.
u-158-
165
;4*
P
PA4F:Z) CITED
le, 66, k8, 88, 9894
38, 93"54, 66, 96, 9889 ,
92, 95
9892
9192
89,4 9092, 93
95 P66, 9892
08, .93
, 92
93 -
59, 9743, 84,. 95
48) 9.5
930
9533, -44, 56, 62,
85, 91., 95, 96,
42, .93
95( 50, .96
50, 58, 96, 97'57, 63,- 84
-52), 96, 97
9292,-. 97
r
.vr
AUNOR.' .
Barchie-siA.Barclay, R.
Barclay, R*Barnes', R.H.*
Barnett`,
G.0.*
Bashook,1.Bashook,-P.
40.s.hol, 1)6.G.
BashooBassett, J.*hates, B.10
Bauman, nk.*'Bealcher, J.*Bicker, ICC:*Bicknell E.P.
Bedard, k IleBedard,Beland,
BenageBent ,,B.G.
Bens., p.1.10#
Bertheim, J.W.*Berni; R.Berni, R.,Berni, R.Bernsteinr B.A.Bertucci;
Best, R.Bird,
Birk, PBjorn, J.C.Bjorn, J.Z.Bjorh, J.C.Bjorn, J.C.'
Bjoin, J.C.
Bjorn, J.C..*
Bjorn, J.C.*J.C.*
Bjorn, J.C.*Blackburn, Jr.*
.e Blir, K.K.
Blake, T.S. fBloch, D.
* Secondary, Author.
ITEM
614
:125
,159
3332
Jl127 yt
128
276
412
422470198102
72.;X50
15r--1
129
130-
417
290 .
73'131
132
133134
135136
74
14139
PAGES) CITED
93909255, 61, .96,
99
99958,
89,, 91
92
,95.
78, 98, 9990,99
,c54
98k._./ 89
91
5, 96, tgp
, 93
`66-,89
95. 67, 98
9549, 96
"01, 97
62, 85-, '97
979545--106
24, 32, 89, 91 ,
92
-92-140 94160
1
35, 9116 37, 92 .
16214 4197
.
27219
141c 20
r
r .
. 94: 92
as89
96
a
k. #
AUTHOR MITE. PAGE(S).
Bloodworth, L.P.*'Bloom, J. S'
109.142
92fi3,
98Bloom, J. .- 143 66,Blum, H.T. 144 92Bogdpnotf, A.D. -145 90 eBonkOvsiy; M.L. , 146 57,-Bonkovsky, M.L. 'i 615 '98
Badoer, B.B. z 147 89
pneY, V.. 2--'----;--)
8,
Sergsdorf, L.R./
1148 94Bostock, T.W. 149' 93Bouchard, R. 15Q 89Bouchird, R. 151. 91
4-
4.
66, 85, .91,
96, 98
f
59,,% 96, 97
Bouchard, R,e.*Bowen, G.* '*Boza, R.A.
536
135152
.
-
33, 919793
,.
Bragg, F.E.* 272 92:Brandeis, J.F. 153 92 .4. ,
Brashear, J.M.* 119 33, 44," 56, 62:, 85,-91, 95, 96
Breinig, J.* 371 63, 97'Brentwood VAH 616 k 98 e
Brpotwood VAR. 617 98 4 -Brain,_ D. r I54 79, 80, $5,, 99Brawn, Dr. G.C. . 618 95Browning, ,M.H. 3 14, 66, 88- 98Bryan, T.' 155 91 .
Bryant, B.G.* 522 94Brydon, J. 156 60, 92., . 97 .
Buchan, R.F. 157 :,./ 29,. 90.
Buckley, V. 4 5 ...___ c
Buhac, I. 158' 92Burchell, K.* 125
1
90 .
Burchell, K. 159. 92'Burger,. C.S, :160 .35' 91Burger, C.S. 161 '37, 92Burger, C.S: 162 94Burger, C.S.* . 197 '90
Burn, M.A. 163 96Bt,tinett, C.F. 164 96Harrill, G.C. 1615
.
4.
.94
Cadmus,-M.G. 166' 61,'" 97
Cadmus, M1G. 167 50, 96
* Secondary Author.
4
-160167
;go. .".
r.
AUTHOR ITEM I PAGE S Chin)
CalhOun,.N.R.Campbell, A.T:*Campbell,
Cantrill, S.V.Cantrill, S.V.CEurtriLly
Cantrill, S.V.*Cantrill, S.V.*Cantrill, s.u.*Cantrill, S.X.*Caplan, L.CareyCarlson, S.
CFnevcili, D.*Carneyali,
Carnevali, D.*Carothers, R.A.Carothers, R.A.Carpenter, R.R.*Carr, ICI.*Carson, P.
Caserta, J.E.Castellan, N.J. irCastleman, B.Castleman, -B. -1\Caton, R.*Chttmbers, W.
Chappelle', M.L.
Christie, R.W.Christie, R.W.Chyatte, S.B.Ciuca, R.L.Clark, A.*
ClEtr , M.E.*' Cohen, J.*,
Coles, E.C.Conti, R.M.Conway, M.E.Convoy; M.S.:Cook, F.J.
-Cooper? J.F.*Cordm J.F.*Corale, F.Cowan, D.B.*
* Secondary. Author.
J
11
168490169170171172
p
493. 591 kV
173
21"10 (48
( 49619620465
_175176177
4.3.773798
466`22180183.18218323
53. 5383.84*76.510185 ,-
'621186'187 N188 1
169336189
342
94`
52,!IA,7278,1 2,949976,9892
889,9,
889395/93.
27,,30,`97,9,
90,*89928,
'7.94,9494,99313,929294948961,79,989044,00,
-98,6o,
5?,84,
98,76,
77,
12,88
9089,988892
88
95.
4.5,
99
84,.99
9997
1,
94,
9948686, -99;
90, 99i
13, 88
90
881
94", 95
'4N
1
.,
/
AUTHOR rtEM PAGE(s CITED
Cox, B.* 3314 91, 93, 96Crabtree, M.K. 190 504_ 96Crawford, G.B. 191 43, 93, 94-Creighton, H. 192 g6Cross,'H.D.* 75 24, 32, .Rog, 91'Crois, H.D.* 160 35, 91Cross, H.D.* 161 37, 92Cross, H,D.* 162 94Cross, H.D. 193 92
ss, H.D. -194 31, 89, goss, H.D. 195 93
Cross, H.p. 196 93Cross, H.D. 197 90*Crounse, R.* 507 93
..-
Dartmouth 665 95Daubentdre, M.J. 24 9, 16, 88, 89David, M.L.* 11, 88Davis, B.C. 98 54, 65, '96, 98Davis, E.,.. 622 85,-96, 97Davis, J.H?* 101 94
Day, B.C.* 365. 89
Dabski, A.* 600 94
Deininger, J.M. % 25 .88Deiligger, J.M. 26 89
DeJong, N.* 533 -95D&4arcom M.* 559 95Deming; B. 199 93de7ries, J.B,* 466 92Dietrich, P.A. 200 98, 99Dietrich, ?.A.* , 592 68, 76, 78, 98,
,Dietz, R.R.* --62
99---------88
,r
201 38; 93El dale, S.M. 202 93Dixon, R.H. 203 j 44, 91, 95
Donabedian. A. 204 34, 91Donaldson, F.W. 205 \ 78, 93, '98, 99Donaldson, F.V.* 58950Y
\1 98
Dorsey, J.L.* 274 i1
99Draper, W. 206 93Dressier, J.* ( 142 63, 66, 85, 97`,.
98Durand, M. . 27 10, 88Dyer, E.*
, 99 49, 96
* Secondary Author.
ti
_169 A
3
.1 -
AUTHOR IT # . PAGE(S) CiTELY
Eastern4tate/Hospital 623 95, 97, 98Easton., R.E. , 76 26, 89Easton, R.E. 207 190Echternachi J.L. 208 53d.(3z,r, W.14.11 150 89Eddy, W.M.* -151 :91Eddy, W.M.* 536 33, 91Edwards, B.S.* 31
vllinoy, B.J.* 246 914
EZlis, F.J.* 87 25, 89Ellis, G. 209 27, 90Endicott, J.* 510 94Fnellw, A.J. 77nelav, A.J. 210 93Esley, C.E. 211 89Esley, C.F. 212 33, 91Espenscade, ?.W. 213 90EsterhAy, R.J. 214 91frog, D.* 516 94
Fay, H.J. 215 93, 95Seeney, S.*Feinstein, A.R.)
53216
-4688
90Feinstefh, A.R. 217 29, 90Feitelberg, S.B. - _6214 .93, 94Felix, W.R. 218 92Fernov, L.C.* 360 94Fessel, W.J. 219 36, 91Field, F_ it. 220 59, 97
'_Field, F.W: 221 98Field, F.W. 615 98Fleiss, J.* 510 947142ral ng
222- 89, _90-Fleming, M.J.* 198 54, 65,, 98, 98Fletcher, R.H. 223 145, 84, 91, 95Fortin, L.J.* 153, 92Fortne'r, C.L.* 214\ 91Fortpine, P. 2214 89Fortuine, R. 225 T9Foss, B. 226 63, 85, 97'_,ceder, D.R. 227 93Framm, D.H.* 594 . -94-Freeman, R.B. 5 9, 11,' 16, 88,
89French, P. 625 95Friedberg, S.J. 228 90
* Secondary Author.
I
J
AUTHOR
Gane, D.
Garsit, C.Gardner, J.'Gartner, L.B.Garrell, M.Gaskins,.J.R.Gaviria, B.Gaviria, B.Gebbie, K.
Gent, M.*Gerken, B.
Gertzog, J.
Gilandas, ArJ.Gilandas, A.J.Gilandas, A.J.Gilroy, G._Gledhill, V.X.'
Gleehiii, V: X.
Gohrke, C.'Goldtinger, S.E.
Goldtinger,Goldtinger, ,S.E.
Goldstein, F.Golodetz, A.Good, V.M.Good, V.*Goodwid, J.O.'Grabois, M.Grace,-M.T.
Friedman, H.H. 78Proom, J. .-229?room, J. 230'
Fry, V.S. , 28Furth, E.' ' 137,
Gale, J.* 279Game, D. 231
Gane, D. 232Gane, D. ..255
Game, D. 234Gane, D.' 235Gane, D. 236Gene, D. . 626Gane, D. tat 627
628
29483
237238
239240
629
30
202241
242243244245
246247.248.
69249250251252253
488254
'31255256
* Secondary Author.
ITEM I PAGE(S)
- .171-164-
N..89, '9233, 145, 91, 95907, 8895
42, 9376, 85
51, 81, '96
51, 9651, g51, 9681, 85, 99, i0053, 9653, 57, 61, 66,
96, 97, .100
53, 96, 9(10, 88 '
41, 94 .
42, 94
9094
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9361, 97 '
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36, 9128, 90
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0393
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98
...
AUTHOR ITEM IV
Granger, C.V. 257Grant, R.L. 258Grant, R..L. 259Grant, R L. 260Grant, RIL. 261Grant, R.L. 26?Grant, R.L. 263Grant, R.L. 264Grant, R.L.* 284
Grant, R.L.* 508Grant, R.L. 630Grant, R.L.Gravanis,M.B.
631_____
265Gravamis, M.B. 266.Gravamis, M.B.* 316 - ..;--
Graves, S. 267Graves, S. 268Green, H. 269Greene, R. 79Greene, R. 270Greenes, R.A. 271Greenfield; S. 272Greenleaf, D.* 273Greenleaf, W. 273Greer, D.S.* 257Grossman, J.H. 274Gruendemann, t. 32
GullicOon, G. Jr.* 201Gunn, A.A.* --125Guthneck, M.* 115
Hall, W.D. 2/5Hanr_W,D, -317-
Handl, M.E. 33Hammett* W.H.* TiHammett, W.H.*Hammett, W.H.*Hammett, W.H.
Hammond, K.Hammond, K.R.Hammond, K.R.HammOnd, K.R.Hammond, K.R.Hammond, K.R.
* Secondary Author.
1
127128276
27734
35
36
37
38sr
PAGE(S)*CitED
. 9393
r---1.,,39, 9339, 9339, 90, 9392
93
93394_ 61, -917 93,
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11, 8889
89, 91
92
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88
19, 889, 88
89,-
---
sso
' AUTHOR ITEM I PAGE(S) Lain)
Hansbarger,L.C.*Harmer, B.Harmon, S.R.*
..)6/Harmon, S.R.*
Harris, B.L.
561
6
356
35139 ,..
94
7,13,9093.
as
88
Harris, D.*Hartman', M..
387
278 .
98. 96
s
.x
Harvey, R.T. 279 42, 93Haswell, J. 28d 94Haswell, J. 281 .94
rHawken, P. 282 7; 57, 97Bawtins, C. 283 30, 89, 90Hawley, C. 28 39, 61, 91, 93,
97 .
Hawley, 508 94Hayes-Roth, F; 285. 40, 70,- 93'Hayes-Roth', F. 286 '40, 69, 93, 98Hayes-Roth, 287 93'Hedin, B.* 63, 9.7
Henderson; B.* 90 0, 96, 98Henderson,. R.; 633 95
?'Henderson, V.A.* .6 7, 13, 88Nemderson,Y.A. 140 7, 13,' 88Herjaaic, M.*. 51d4 94, 95Hertnon, P.D. 289' 93Hertz, C.G. 290 95Hess, J. 633 95Hil1, A. '291 96Hill, P.A. _292 96Hill, R.* 480 96Hirschowltz, B.G. 293 93
"1 Hobel, C.J. 294 94Hodges, C.V.; 126 II- .
(Holland, H.R.HolloWay, R.M.
295296 94
Hoames, R.H. 297 9-Hood, J.N. 298 '90, 93Horn, S.P.* 505 95Howard, F. 300 96Hoyt, W.H. 4 299 93Huff, L.H. 301 61, .97Humphrey, J.* 461 92'Hurst, J.W. 80 A 24, 27, 32, (34,
42, 51, 61, 69,72, 76, T7, 85,
* Secondary Author.
.
0
.
ill 3 '/
-166-
W,/ 99
I S
.
AUTHOR' ITEM PAWS) GITIW
Hurst, J.W.* 94 7, 24, :33,. 35,
38, 39, 42, 44,46; 48, 50, 51,56, 57, 60, 79,
Hurls 17547'
,
85,
9090, 9%1
30'2 t 92'11 Hurst, J.W, 303 32
Hurst, J.W. 304 35, 91Hurst, J.W. 305 27, 31, 50, 96Hurst, J.W. 306 89Hurst, J.W. 307 92Hurst, J.W. 308 90, 9Hurst, J.W. 309 92Hurst, J.W. 310 91Hurst, J.W. 311 92, 93, 94Thirst, J.W. 312 91Hurst, J.W. 313 90Hurst, J.W. 314 92Hurst, J.W. '315 90, 95Hurst, J.W. 316 94Hurst, J.W. 311 28,- 29, 90HUrst, J.W,* 556. 90Huston/F.* 134 62, 85, 97Hutelnyer,.C.M.* 33 11, 88 _
Ingber, J.S. 318 94.Issenberg, H.J. 319 29, 90
20* 84, 95Iverson, H.* 607 90
Jacobs, S.* 600 94Jauron, 0.1),* "I 56 88Jensen, D.M. 7 13, 88
--jervey, 321 89Jessop, P.I.* '300 96 i
"I'JChn, P.K. 322 90Johnson, E.* 8 49, 96Johnson, E.* 387 98Johnson, E.L.* 388
.
95-Johnson, M.S%* 489 94Johnston, A.* 122 96Jones, J.W.* 561 94Jorgensen, L,A.* 324 93Judd, S.J.*
. .43.4 44,,-,;
47, 91, 95
* Secondary Author.
.467-
,
, , .
AUTHOR ' ITEM 1 AGE(S) CITED,
Kalk, C.E:* . " 332 90 \-----.
Kane, R.A. 323 04
Ciall':R.*
99 49, 96
R.D.
.
324 93'Kane, R.* 433 -- 97
Kane,, R.L.* 604 96
Kantor, T.G. 325 93Kaplan, A.D. 326 92
Kasowski, M.A.* , 153
Kaufman, T. '327 94\-.,.
'Kelli, K.* _ 35 88
Kelly, K.* . 36 '10, 08
Kelly, K.* 37. 9, 88
Keller, K.* 38 k. 89
"Keily,--K,L-- ,41 88
Kir117--K.4.
Kelly, K.J. 43 as
Kelly, M.E. 328 4 54, 59, '60, 96,
, 97Kelly, M: E. . 329 97
Kenny, 14.* 142 ' 63, 66, .,E6-, 97,
4 98
Kent, D.F. 330 - -93
'Kent, D.F: 331 90
Kessner, D.M. 332 90klmble, J.J.* 199 93 '
King, I.M.* 24 9, 16, 88, 89
Kinney, L. 333' 55, 61, 96, 97
Klexin, §.\-11.* 271 99Kline, G.* 202 93Klonoff, H, 334 91, 93, 96Kneedler, 4. .. 44 88
Kniffin, W.D.* 551 92Koepsell, T.D. 274 99Kohler, A.* 637 95'Komaroff, A.L. 335 92
.
, ,
Komaroff, A.*, 472' 92KomLrita, N.I. 45 . 8, 88
Kramer,'* 46 14, 15, 86, 88
Kritmer,'a.R. 336 So, 99 ... .
Kumar, L.* 40 42, 46; 84, 94'
Kumar, V.* 404 42, 46, 114, 94,
.
Kuwahara, J.*.
32495 4, 96
93 -,
.
* Sea6ndary Author.
.()175
-168-
AUTHOR
Lambert, K.lambert, K.Lambert, R.P.Langley, G.T.Lantinga, L.*Iapenas, C.*Larkin, P.D.Last, M.
Lavin, .A.*Leonard, P,Lesnick,
Levine, E.*-Levy, J.D.Lewis, E.*Levis, K.*
Levis"L.Lintign, t.R.*s
Linn, B.S.*Linn, M.W.
Lipkin, M.Lipp. M.Lipp, M.
Lipsius, L.H.Likow, B.I.Liston,Tg.Little, B.
Little, D.E.Little, D..Little, D.
Lloyd, G.
Longabaugh, 1)..*
'Longabaugh, R.*
Longabaugh, R.*Longabaugh, R.*Longenecker, D.P.Lorigan, J.H.Lawe,Ig:R:Lyng, F":14.'
Lytel, F.Lytel; F.
Lytel, J.W.*Lytel,.J.W.*
* Settodary Author.
211. II? 0 . 12
ITEM I PAGE(S)
337338339 ,
340279466
. 81341.30'342
8
51, 96*58, 97938942, 93
92
98.89, .9126, 896o, 97'66, 98
673 8o, 100343 90546 94
. 485 959
16, 88, 8947 16, 88
497 9531414 91, 9531414 91, 95 -
3145 903146 91, 933147 36 -1
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10 9,' 12, 13, 8848 \ 9, 88149 88
352 92227 93285 4o, 93286 40, 69, 93, 98287 93353 . 90.634 93354 90,, 93; 95"355 914
'356 903,57 91356 90357 91
176-169-
AUTHOR 7 ITEM # PAGE(S) CITED
--/McAnulty,E.H.* 713 94McBarron, W.! %.--" ' 431
55,632ft 96, 97
McCain, R.F. , 501 8
McCann, D. 635 91, 92
McCanse, A. 358 89 '
..! McClosky, J.C. 359 98
f McColl, I. \ 360 94
McCormick, M.* \ 198 54c, 65, 96, .9.8
McCracken, J.F. 361 33, 91McCraith, D.L.`Sane, J* \ilk
272472 .
9292
McFarland, G.* 83 96
riff, E.P.wire, C:*
36284
96, 97
McIntyre; N.* 352 92
McIntyre, N: 363 89
'McIntyre, N. . 3614
McIntyre, N: 365 89McKnight, R.S.
..
McKnight, R.S.366367
.9393
idcLean,.P.D. _ 368 93 -
McLeod, D.* _ 388 95McNeely, B.A.* .178
McNeely, B.A.* 179 89McNutt, H.* 'P 328' 96, 97McPnetridge, L.M. 51 10, ,88
Mackay, I.R.* 248 45, 46, 84, 95
Mackay, I.R.* I 339 \ 93
Mackie, C:* 360 94
Macneil, A.R.* 598 95Mae J .V . .369 92, -94 %/-
Mager, .F. 11- 11, 12, 88
Magt11, K.* 135 97Magill,K* , 226 -63, 85, 97Maletzky B.M.* 264 93Malltaan,-W.11--- ---6054 56, 96
Malloy, J.L. 370 51, 96,' 98.
Mann, W.V.* 533 95Manthey, M.E. - , 52 .88Mantle, D.D. .
371 63, 97Mantle, J.,*
v371 634 97
Margolis, C.Z. . 372- '91
Margolis, C.Z. 3731.
NI. 92, 95
Margolis, CA. 574 92
* Secondary Author.fj
177
4,
AUTHOR
Margolis, Q..z.
Marks, G.S7*Marshall, J.C.Martid, A.*Mason, R. -
heney, R.*her, B.S.
Mathews, J.D.*k.M.
Matthis, E.J.
Matthis, E.J.
Mattingly, P.H.Mauksch, I.G.May, P.R.may, P.R.
Mayers, M.G.Mazur, W.P.Mazur, W.P.
Mazur, W.P.Mazur, W.P.
Mazur,. W.`Ma:zur, W.P.
'Mazur, W.P.Mazur W.P.Mazur, W.P.Mazur, W.P.Mazur, W.P.Aszur, W.P.Mazuf, W.P.Mazur, W P.Mazur,Mazur, W.P.
Mazur, W.P.Mazur, W.P.Mazur, W.P.Mazur, W.P.Mazur, W.P.Mazur, W.P.
Mechanick, P.*Mehigan, J.A.Heldman, M.Heldman, M.J.
. * Secondary Author.
rTEm # PAGE(S) CITEI. iw
34--' 46, 84,'538 .9253 aa1' .
37-6
1
377248378
379...
38034254
6366371282
381
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9149, 96
98 . ...
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95 .
97,
89
.
93,
'AUTHOR
4 Meldmian, M.J.
$ellner,Messick, J.*Metz, D.*Meyer, ¶
1SeY:ei`s, A.*
' "Michael, M. Jr.':MIkell, F.*Miles , J .E.*
Milhous, R.L.*MilhoOs, E.L.Milhous, R.L.Miller, D.Miller, E.
Miller, S.I.L. Milner; /3*. )1
Minehan, ?I*
Miahelevic4.,D.Mitchell, P.R.
' Mitchell,. P.E.
Mitchell, P.H.
*Nattier, B.S;
Moffett, C.*'
14,09.1:9,
Molbo,D.*. . .
MolbO, D.
MoIitor, A.M.*Monson,
Moontry, M.24.'
_Mekrgan, K.*
Morrell, Ce.*
Mosser,"R.S.Mosszaan, P.*,.
Mrozek, R.
Mandinger, 14,0."
Mtmdinger, M.O.lin, 11..L. 4)
r,
40.
ITEM # f PA E B CITZD
388/*'389
637
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;390374
391
319368253'
392
394
395.202
396
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397,
398
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9, .88
1,40
74, * Secondary ut14-.*
V.a
_ AMOR, as ITEM #
Naham, Lag. f '403AK
Nerang, A. ... e .404
National League in? Nurslng."Education 13
Nitional League for Nursing 85
....
98,'National Lease For Nursing -86k
"I National League. for Nursing 405National League for Nursing 406 -
...4 Neeion, F.A. , .. 87 --
Nee lon,'F:A. 407Neelon, F.A. 408Nefil, E,14* ,/ 256Nelson, G.E.* 246Nelson, G.E.* . 369Nelson, G.E.' 4081
Nelson, G.E. 410Nelson, G.E. 1411,
Nels6n, G.E. 412'Nelson,`
'1.
'592S.
98,
OW r,
PAGE(S) KITED,,t 91
42; 46, 814,-;914,
95...
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evble, D.I...--
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--, ,47; 91, n.' -Revell, J.P. 415 91
- '-: Nicholls, M. E-0! '57 '9, 1T, 18-, -88,
,
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Nichofsbn, C.* . 132.
61, 95, 97/...
Nicholsion, D.*
Nies, A. -1.4091: ' 9t675; 991Niland, M.B. . 417 N,
. Nolan, M:G. 1 1418 tit, 98...
eliorraan, A.- . 215 C4/ 93, 95 . -
Novell°, 3.1i. 420 141, 94.-
- Nuckolls, J.G. *2.1- 92.e
Nutting, M.A. 14 z.,, 88, .
-O'Connor, 'E.*/ ''.3
. .
98
55, 61:, 96; .97.
O'Connell., A.L.
O'Connor, F Al 7, .92-?'.'
)
149O'Connor PAT- 424
F.JI. 658 .149f4.
* Secondary Author..: 4
.
1 8-1737
4
'AUTHOR - ITEM1 ,PAa(S)IcrrM)l '
O'Grady, T.R:Orr,
Otway,
Owen, L.* -,..
.Page, .0.C., ,
Palisit4 H.E.Palken, M.*
Palmer, T.E.Palo Alto VAHPahkratz, L.Pepper, S.*.Pardee, G.P.*Pardee, 6.p.*
.
Pardee, G.P.*Parker; B. A
PaYker,'R.D.*
.
.
425
109426_'546:
.
427, - J5
126428
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76
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143430594
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95 N.
93
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95
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97 -
it 94-Pass, T.A.*. c 0)472 . 92Payne, S. .431 55,\,61, 96, 97Pearson, Aii.C.* 365 89Peck, R.L. , 432
\..
92.- .
r'''.ediatt-it Group Services 660 95 ,.
Pellicore, R.J-* 387' 98Pepper, D.A. 2 L:433 _
1 Sq. '._ , __
Perloff, E.* 14 62, 85, 97?erleff, T.N,* 290 / 95Perry, A. 0 434 93 6
Pfifferling, J.H. 662 4 31, .91Pfifferling, J.H. 663 91Pfifferling, J.H. .%. 664 42, VsPfifferling, V.* 664-` 42, 94 ,
Phillts, D.F. .435 R7 e 89PhiSlips, D.F. 436 96, 99-1,7,-Phillips, D.Y.
.437 91
Phillips, H.R.* 274 99Phillips, T.J. 438 89
( Pierce, M.* i :430 97Plernot, R.W. * 471 95Pittman, K.*--' 323 .56, 64, 647, 85,:
96, 98Pittaixtrg VAH 4.
.
669 . 95 ,Podeil, R.N. 43g 91 ..'''\
Pele,:D.D.- . 2561 93
* sec6ndary Author.
1.81
14
'AUTHOR PAGE($) C1ED
Poole, R.* %149 93Popiel, E.S. 441 97Potts, L.R. 442. 94.Pratt, D.* 0629 95Prince, R.* 27 10, .88Priori R.E. 271. 99Puller, M.L. 459 94Putsch, 'R.W. 460
9992Putsch, R.W. '461 ;
.
Quirch, J.* 539 - .99
Ra.ckley,
Rakel,R.E.371
1462.
63,
Randall, RIB. 463 92Rashidi, N. 464 94
J:"Ready, H. - 40* 94
49, 96Reardon, F.D. cz-41 -64 97Reed, D.E. L65 91Reed, D.E. 488 92Reid, M.S.Reiffen, B.*
467
- 335
98
92_Reinstein, L. 468 93; 95Relkernis, .K.* 114 89Rendall,: M.* 360' 94
H 489 91Renner, J.H. `470. 99Renner, J.H: 471 95Revere, M.* 606 94Rhodes, A. 472 92Richert, R. 473 94, 95Richert, R. 672 '95'Rietz, C.W.* '265- 94.Pietz, C.W.*.
L.A-*266,,
62,,'94
88Robbins, A.* 271 99'Robinson, A.M. 474
. 55,, 96, 91Roebsler, L.M. 329 91Rogers, A.I. I , 475 90Rogers, K.D.* 465' 91Rogers, T.V. 476 94Rose, L.F.* . 318 94R enblueth, A. 477 5Ro hberg,J.S.* 2 8, 10, 88Rothberg, J.S. , 60 8, 14, .88,
e
.- Secondary Auitthor..r
r
89, -
4
AUTHOR
Rothenberg,Rothesteia, E.Bothwell ,,, G .
Rory, Sr. C,
Rubin, C .F .
Rubin, C.Rues s , J.
Ruff, G.E.Rums ey , J.M. -
Russell , Rt*
Ryan, B.J.Ryan, M. P *
Ryan, M.P.Ryback , R . S .
aback, R . S . *
Ryback , S.
Ryback-, S .
*Ryback , R . S .
1-
Saba , V.
St. John, D.
Seitz; S. W.
Sandia.* , L. J . *
Samdlow L.J *Sah4low, . J . *
Sandlow, L .J
Sandlow , L.
Savett, L . A .
Savett, L.A.Scales, E.J.Schacter, , S . *
Schad, D . * .
Schell, P .L.
4 Schlachter, , H. *
Schmidt, E .
-Schbehir,,%
SOpei der R.
Schneider, R*Sckiei der R .
Schoff, , M.
School, R . *
Schulman, 3.
. SchAlt z , J R
Schultz, J R *
ITfl4 I PAGE (8 ) CITED
_594418;479
6162
480
94..- ._- 42, 941
979, 16, 88,
62 / "
96
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,
253483.
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127 89, 9.1128 92276 95486 9Q487 94
488 64, 85. 98489
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* Secondary Author,. to, /
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89,989427.,
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30, 99-98
v./
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AUTHOR -
. Schuster, J.S.'
'*Schwab, N...._
Scott, E.M.Scott, L.Scott, S.R.
Seawright, L.C.Sehdev, H.S. .% ...
Selander, E.*Shapiro, E.N.*Shaw, S.W.Sheehan, J.T.Sheehan, J.T.*.Sheehan, J.T.'Sheffield, E.Sheldo, M.G.
\
Sherman, H.4 Shorapa, M.Z.*
Spbermam, L.*Silber&n, L.
, . Silverman, M.E../
Silverman, M.E.
, aSinhorg ,. D. W.
Singer, J.*Smilkstein, G.
-itli, B.'
Smith, C.*4ith, ILL.*Smith, D.*
D.M.'Smith,
Stith, D.M.Sr.ith, D.,W.
4111,
th, J.G.h L.C.'
th L.C.derman, A.'ary., H'
southAll, i.*Sox, H.C.'Sox,%H.C.Sox, H.C.'
* Secondary Author., -
4
. MS( i PAGE S Crime
461494
92
97 -
495 47, 95542 96
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AUTHOR
Specks, C.*Spellacy, W.N.Spitzer,.R.L.Spitzer:, R.L.Starfield, B.H.*Stern, D.*Stevens, D.P.Stevens., J.Stewart, M.M.Stick ley, W.T.*Stickley, W.T.*Stick ley, W.T.*St..4-at..mann, W.C.Strauss, B.*Stria/L:1=d, R.G.*Strong, M.L.Sturm, j.E.*31ers, R.W.*Svcs er, S.Swisher,. S.*.Svitz; D.M.Switz, D.MSyst=e-di
--Tagger1;-..--Ta4ger;, M.
40 Tait, I.Taylor, j:Taylor,Taylor , j.W.Teetqr, , D.S.Templeton, 3.*Teteberg, B.*Tqteberg,
kips R.K..rspkies; R*
7norriElOn 1w* C. D.Thompson 7'S PThom-pson,S.P;
Illampson, S.P. .Thdopson S.F. tThorne, 14.0.Thurnblad, R.*
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89510,513-
. 505633248518512373374_375
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Tippett, J.Tolby, B.E.
Tompkins, R.K.*Tompkins, R.K.*Tompkins, R.K.Tompkins, R.KiNTruax, C.B.Tryon,.A.F.Tudor, J.M.Tufo, H.M.*'Tufo, H.M.7
Tufo, H.M.Twin, E.J. -
Twitchell, J.C.*Tvitshell, J.C.*
AUTHOR ITEM I
529530326509
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"VInBuren, H.C.* 536'' 35Vancini, M.
Vannini , M.*, ) 36Vanciai, M.* 37Vancini, M.* 38van End, J. 541 'VanMeter, M.J. 542Vash, G. . 543Vaughlul-Wrobei; B.C. 90-Veterans Administration> 677Vickar, G.M. ' . 544.
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Vormimer, J.J.* 327Voyto'1ch, A:E. 550Voytovich, A.E. s 551
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Waisbn, B.A. 552
Wakefield, J. 93Wakefield, J.S. 553Walia, B.* /4o4 .
Walker, H.K. 94
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Walker, L.G. 557Wallace', R.B. 558Walsh, M.B.* 16Walsh, Ma.* 17
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4 Whyte; F. / r598-Widmer, A.43. 599,Wiernilp P.H.* ' '214WilltaAs, C.L..,
i X49Williams, D.H. . W600
7. Williams, J.I. 601- Wigan, M.J. 652r`
Woladarski , J. *4 ( 389* Wood, C-.*, r\ 492
Woody, M.F:* . 41--- 94
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W9olley, F.E. .99
Woolley, F.R: 604Worthley, L.I. '4605'
Wright, R.K. 606wynpugh, E.W.* 352 '
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larnall, S.R. 1 -93
Yarnall, S.R. 100
Yarnall, S.R.* 120Yarnalf, S.R.* 121Yarnall,`-7S.R.* ' 320
Yarnall, S.R.* 553Yarnall, S.R. * 607
arnall, S.R.* 608
vnall, S.R.* . 609
Young,.D.W. . 610 t"
Young, L.A. '., 611Yottrtee, S.A. 505Yura , IP. 16
Yom, H. / 17
*Yura,-H. , 612
. Zarour., IL! 240Zimmer, M.J, 67mr-tpr ; M.J. t .
Zither, H4 J .* ' g .
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-182- '
IAGE(S) CITED
i. 95
9391
93914
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AUTHOR ITEM I PAGE(S) CrilD
Zilmerman, D.S.'Zoog, S.
I
.
69100
\ I2183
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C. S. GOVOuritotT
9, 12, 8891, 92, 97
1
!RATING OPTIC-I 1077 p - 131.111
