problem-oriented record

(POR) an approach to patient care record keeping that focuses on those specific health problems of the patient that require immediate attention and on the structuring of a cooperative health care plan designed to cope with the identified problems. The components basic to the POR are: the data base, which provides information obtained from the variety of sources required for each patient regardless of diagnosis or presenting problems; the problem list, which contains those major problems currently needing attention and serves as the basis of a plan of care; the plan, which specifies what is to be done with regard to each problem; the progress notes, which document the observations, assessments, nursing care plans, physician's orders, etc., of all health care personnel directly involved in the care of the patient. See also SOAP.