Question

Difference between traditional and problem oriented medical records

Answer 1

The traditional medical records uses an abbreviated story form where charting is divided into sections or blocks, that includes admission data, physicians' orders, history and physical examination, nursing care plan, nurse's notes and graphics, progress notes, and test data. Its emphasis is place on specific sections or sheets of information. 

Meanwhile, the Problem oriented medical records uses an outline form or a master patient problems list as an index to chart. It is a method of documentation that focuses on the patient's problems and not just on the diagnosis.