Electronic Patient Problem List Content Development and Its Challenges: A Case Study

Abstract

Introduction: Problem-oriented medical record (POMR) is a method of documentation and medical record organization. Problem list is the main component of POMR and the core of the electronic health record (EHR) definition. The aim of the present study was to explain the requirements and challenges in establishing an electronic problem list in hospitals. Methods: This descriptive-applied study was conducted in 2016 in Alzahra Hospital affiliated with Isfahan University of Medical Sciences, Iran. One of the requirements of patient problem lists was content development that, after designing the software, was implemented at neurosurgery and neurology wards. Results: Establishing an electronic problem list showed that content development was its most challenging requirement. These challenge included terminology, patient problems documentation, and interdisciplinary documentation management. Conclusion: Implementation of the problem list as a key component of POMR, especially in inpatient settings with various treatment groups, has challenging requirements. Thus, it requires knowledge and administrative, financial, and technical support.

Keywords

• Electronic Health Records
• Medical Records Problem-Oriented
• Patients