Problem Oriented Medical Record
รูปแบบการเขียนรายงาน ประเด็นทางจริยธรรม Scope รูปแบบการเขียนรายงาน ประเด็นทางจริยธรรม
Medical Record Clinical Reasoning reflection of data gathering Hx, PE analysis diagnosis data base problem list new information assessment summary assessment progress note treatment / workup plan plan of management
Use of Medical Record enhance thinking legal document process communication (medical personals) research study
Good Medical Record valid complete precise communicable aim component valid data base legal document complete reasoning, coverage problem list thinking process initial plan communication precise progress note research study communicable understandable summary hospital course
Problem Oriented Medical Record S O A P Problem: UTI Subjective data ปัสสาวะแสบขัด 3 วัน, ไข้สูงหนาวสั่น 1 วัน Objective data T= 39.5, BP 90/50, PR 100, tender Lt. CVA Assessment fever with chill →infection, dysurea, tender CVA → source = kidney cause = most likely GNR hypotension, rapid PR → impending shock? underlying ? R/O renal stone, DM, CKD Plan of Mx NSS infusion → monitor : BP, urine output UA, urine gram stain, C/S, H/C Cefazolin IV, adjust ATB after culture result Plain KUB / US, FBS, Cr
Problem Oriented Medical Record S O A P Problem: acute fever Subjective data ไข้สูงหนาวสั่น 2 วัน ปวดศีรษะ ปวดเมื่อยตามตัว ไม่มีโรคประจำตัว Objective data T= 39.5, BP 110/70, PR 100, looked ill, no anemic stiff neck – ve, no abnormal neurological sign paranasal sinuses – not tender H & L - normal Abdomen & CVA – normal Assessment acute febrile illness without source of infection, normal host → sys. inf.- virus, ricketsia, malaria, mycoplasma Plan of Mx CBC, blood smear for malaria cold agglutination, Weil Felix test, viral study H/C doxycyclin IV
Ethics consideration patient right third party reference self respect