1Pediatra di famiglia; 2Medico di medicina generale
*A nome del Gruppo di Progetto Cesper 2010: Roberto Bussi, Mattia Doria, Fabrizio Fusco, Vitalia Murgia, Lorena Pisanello, Franco Raimo, Valter Spanevello, Giacomo Toffol, Giuseppe Ventriglia
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Key words: Clinical activity data, Clinical diary, Problem-oriented medical record, Primary care paediatrics
The personal computer is nowadays a common presence in the daily activities of primary care paediatricians and a structured medical record is the most used tool in order to memorize information and clinical activity data. Long time clinical activity medical records, either written or stored in computers should not be limited to the traditional “clinical diary” that is just the temporal sequence registration of all events and news concerning the patient. It should instead be stored in a structured, rigorous problem-oriented system: the problemoriented medical record (POMR) theorized by Lawrence Weed in 1969. In order to improve the efficacy of the problem oriented system, paediatricians should keep the daily clinical records as required by the SOAP scheme with data and information registered in a precise, structured way as subjective data, objective data, physician assessment, intervention plan. The efficacy of such disciplined approach to medical record documentation would undoubtedly be furthermore implemented. Primary care paediatrics would highly benefit of this rational medical records organization that collects the daily routine data as POMR and would also improve the care to each patient
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