A system-structured medical record for intensive care patient documentation.

The problem-oriented approach to the medical record has aroused a long overdue interest in the structuring of the medical case file. Clinical information in the traditional record is source-structured and time-sequenced, whereas the problem-oriented system differs by being a problem-structured record retaining still a chronologic sequence. We have found that in acute illness the multiplicity of interacting pathophysiologic processes makes premature application of the problem-oriented approach cumbersome and unwieldy. The formulation of the problem list at an early stage often led to the reduplication of problems, creating disorder in the clinical picture rather than serving to clarify it. Some used the simple cataloguing of events and data as a substitute for clinical judgment and decision making, focusing more upon style rather than content of the medical record. By using a rigid physiologic system-structured "problem" list and a modification of the SOAP (Subjective Objective, Assessment, Plan) subdivision, we have improved the documentation of our intensive care patients. The summary of the patient's stay in the intensive care unit is structured with active and inactive problems, this summary to be further used as the permanent problem list.