The Problem List
The first page of the patient record should consist of a numbered problem list. It is, in a sense, a table of contents and an index combined, and the care with which it is constructed determines the quality of the whole record. Inherent in the problem oriented approach to data organization in the medical record is the necessity for completeness in the formulation of the problem list and careful analysis and follow through on each problem, as revealed in the titled progress notes. The precision of titled, problem oriented progress notes and conclusions is directly related to the precision and integrity with which the problems are initially defined.
KeywordsObesity Anemia Neuropathy Diarrhea Dehydration
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