Abstract
There is no consensus among health professionals on how to structure medical records to serve clinical decision-making. Three approaches co-exist (source-oriented, problem-oriented, goal-oriented), each suiting a different subset of patients. In primary care, the problem-oriented approach is dominant, but for patients with multiple conditions (multimorbidity) the goal-oriented approach seems more appropriate. There is a need to combine different approaches in one medical-record system. In this article, we explain some misconceptions about problems' and goals' that hinder the way to consensus. When putting the approaches into historical perspective, it becomes evident that each relates to a different definition of health. Each approach has its specific merits that should be preserved even when health definitions change. Hence, we combine the merits of each approach into one overarching model, as to show the way to a new generation of electronic medical-record systems that can serve all patients. This model has three levels: a level of problems, diseases, and patient goals, a level of (shared) objectives, and a level of action plans and results.
Original language | English |
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Pages (from-to) | 257-260 |
Number of pages | 4 |
Journal | European Journal of General Practice |
Volume | 23 |
Issue number | 1 |
DOIs | |
Publication status | Published - 17 Nov 2017 |
Keywords
- Problem-oriented record
- goal-oriented record
- patient centredness
- multimorbidity
- primary care
- HEALTH