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.
Medical dictionary.
2011.