Registo médico orientado por problemas em medicina geral e familiar: atualização necessária

Abstract

Medical records are a key component of health care delivery. In family practice, the preferred approach to structure medical records is based on the method proposed by Lawrence Weed’, the ‘Problem-oriented medical record’. It is generally accepted that the ‘Problem-oriented medical record’ comprises three components: baseline data, progressive clinical notes and list of problems. Nevertheless, there is a lack of standards on how to use these sections and, in Portugal, the bibliography on the use of ‘Problem-oriented medical record’ needs updating. This document aims to synthesise and compile the information available, revisiting Weed’s method for practising family physicians and supporting pre- and postgraduate training.