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the problem oriented medical record the admission document you use for clocking patients in the medical assessment unit contains a problem list this is part of the problem oriented medical record concept which Lawrence we'd recommended in 1968 he analyzed the usually haphazard content of medical records and proposed a standardized structure in the form of problem lists and soap notes this approach has been widely adopted on both sides of the Atlantic and now forms the basis of virtually all electronic health care systems the problem lists each medical record should contain a complete list of all the patient's problems including clearly established diagnoses and all other unexplained findings that are not yet clearly attributable to a specific diagnosis the problem list forms an index of everything that is wrong with the patient the contents of the problem list might be symptoms signs abnormal laboratory or radiological findings social burdens or a previously diagnosed disorder the pro...
