Avtor/Urednik		Kersnik, J
Naslov		Problemsko usmerjena dokumentacija v splošni medicini
Prevedeni naslov		Problem-oriented medical record in general practice
Tip		članek
Vir		Med Razgl
Vol. in št.		Letnik 33, št. 2
Leto izdaje		1994
Obseg		str. 223-40
Jezik		slo
Abstrakt		The article deals with data collecting and medical record keeping. Features of problem oriented medical record keeping are described. Minimal data base set for primary care is agreed. The data base is held in several separate portions of medical record in the way to get necessary data always awailable to the practitioner. Easy retreival of data collected is one of the most important qualities of problem oriented medical record. Some forms of data base collecting are mentioned. Change in the present form enables the family doctor to have problem and medication list open in the same time as current progress note. Rest of important data is easily retrieved from other portions of the medical record. Forms of aditional data collecting on patient and his family are mentioned.
Deskriptorji		PRIMARY HEALTH CARE MEDICAL RECORDS, PROBLEM-ORIENTED DATA COLLECTION