Medical risk report: improving patient management and record keeping through a problem-oriented approach

Abstract

The problem-oriented record satisfies the needs of the contemporary practitioner by addressing the transition from diagnosis to treatment. The technique organizes collected data, identifies all patient problems (medical and dental), defines solutions and/or management of those problems, and documents treatment rendered. Predictably, the problem-oriented record will avoid problems associated with malpractice litigation, conform to regulations of third-party payers, and facilitate practice analyses and quality assessment, i.e., through computer-assisted tracking of patient care based on problems and not just treatment rendered. As many practices today focus on a "patient-centered" approach to practice, the problem-oriented record clearly supports such a philosophy in its completeness of managing patient care information. The dentist, in consultation with other health care providers, can and should feel confident treating patients from the growing population of patients with medical risk. By integrating the problem-oriented approach into patient management and record keeping, dentists can more easily develop a plan for the complexities that accompany patients. Whether these complexities are of a medical, dental, or combined nature, the problem-oriented record helps the practitioner organize information, plan for treatment, and document patient care in a complete and concise manner.