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Article
April 1981

Problem-Oriented Medical Records

Author Affiliations

Augusta, Ga

Arch Dermatol. 1981;117(4):190. doi:10.1001/archderm.1981.01650040004004

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Abstract

To the Editor.—  In response to the letter by Goldenhersh and Safis entitled "Problem-Oriented Medical Records in Dermatology" in the Archives (1980;116:751), I would like to draw attention to an editorial entitled "Problem-Oriented Records" published in the Archives (1972;105:534) by Smith and Crounse. In this editorial, the authors discussed the advantages of the problem-oriented medical records and point out that these have been used in the Department of Dermatology at the Medical College of Georgia since June 1971. This form of record keeping has been found particularly adaptable to dermatology, with only minor modifications. To stress the morphologic characteristics of lesions for our residents and students, we begin our record with the objective, which is subdivided into tthe distribution, primary lesions, secondary lesions, and, finally, a descriptive comment (eg, angulated and centrally clearing). After the objective, we complete the data base with the subjective, then assessment, and, finally, the plan.

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