Recording the Clinical Database

Abstract

Since the 1970s, the traditional format of clinical database recording has been the subject of two developments: the problem-oriented record (POR) and the electronic medical record (EMR). The main tenet of the POR is the requirement for physicians to state their reasoning. It allows for the review of clinical decision-making, effective monitoring of the quality of patient care, and communication not only with other healthcare providers but also with medical students. EMRs are considered effective in organizing and reviewing data, improving the quality of care and staff satisfaction, saving pharmacy waste, and improving care coordination among physicians.

In this section, I propose an approach to teaching the recording of the clinical database. This approach applies the principles of learning for mastery by dividing the clinical record into discrete units, beginning with the psychosocial history and the patient’s chief concern/complaint. I list the difficulties students seemed to have in recording the statement of the present illness (PI) and suggest using a format for recording the PI to identify and correct errors in student presentations.