Start studying nursing fundamentals chapter 3 learn vocabulary terms and more with flashcards games and other study tools problem or nursing diagnosis for the patient documentation style more likely to be used in a problem oriented record. Problem oriented record systems four parts database problem list plan of care and progress notes there is a common problem list that includes input from all disciplines. The nursing diagnosis is the nurses clinical judgment about the clients response to actual or potential health conditions or needs the diagnosis reflects not only that the patient is in pain but that the pain has caused other problems such as. Problem oriented medical record n problem oriented medical records l emphasizes the patients problems diagnoses l database n includes assessment data n hp exam admission assessment history baseline labs radiology l problem list n chronologically developed from the database n holistic needs l plan of care n nursing n medical l . Honors geometry circle review problems rumors and rumor control a managers guide to understanding and problems oriented records data base problems nursing diagnosis implementation and evaluation plans discharge
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