Problem Oriented Approach

Problem Oriented Approach The problem-oriented approach was first introduced by Dr.Lawrence Weed from the United States which was then adapted for use by midwives. In its original format, this problem orientation approach was created to facilitate documentation with integrated progress notes, with this system all teams of health workers record their observations from a problem list. Implementation of this problem orientation approach (PORS), canlikened to making a "book" with a list of the problems as a "table of contents" and notes on each problem as "chapters" of the "book". Some terms related to this recording system are: PORS = Problem Oriented Record System, also known as: POR = Problem Oriented Records POMR = Problem Oriented Medical Records PONR = Problem Oriented Nursing Record, which is a method for compiling patient data organized to identify problems Midwife and medic. The traditional problem orientation approach system consists of 4 elements, namely: Basic data is a collection of data / information both subjective and objective since the client was first examined. This basic data includes midwifery history and physical examination. This information is used to develop. Problem List. List of problems an inventory list of problems that have been numbered according to priority. To make it easierto find, this list of problems is placed at the front of the Medical Notes. This Problem List includes obstetric and medical diagnoses. This list can reflect the patient's health condition. These issues are numbered so that it is easier to refer to a particular issue in the client notes. If the problem has been resolved, also write a note and give the date when the problem was resolved and the officer who assessed that the problem had been resolved, so also write the date and the officer who identified the problem for the first time. Thus, this list of problems can function as an index and description of the client. Care plan expected results follow-up is developed for identified problems. The plan of care should include instructions for obtaining additional data, for therapeutic interventions and patient education. Each problem refers to the need for care, by whom, the frequency of implementation and expected results, short-term and long-term goals. A time limit is determined for evaluating the patient's response towards interventions and progress towards achieving goals. Progress notes form a series of information in the systemProblem Orientation Approach. This note is designed according to a special format to document information regarding each issue number and title that has been registered. These notes provide a record of the patient visit for specific problem solving, planning and evaluation. Progress notes are usually displayed in three forms: 1. Flow sheet contains the results of certain observations and actions. 2. Midwife notes/integration provide a place for evaluation of the patient's condition and progress in achieving goals. 3. Discharge records and summaries of midwifery and medical care and facilitate follow-up when the patient goes home. Various formats may be used in recording. However, problem lists, flow sheets and progress notes are the minimum requirements for adequate patient documentation.Progress notes are sometimes plain paper without columns with the abbreviation SOAP (IER) as a guide for displaying patient information.