The problem-oriented approach to record keeping developed by Lawrence Weed is having a sig- nificant impact on the practice of Psychiatry. In this system, the ...
Indian J. Psychiat.,
(1980), 22, 117—123
T H E P R O B L E M - O R I E N T E D A P P R O A C H IN P S Y C H I A T R Y H . D. CHOPRA 1 , M.D., M.R.C.Psych., M.R.A. N.Z.C.P., D.P.M., F.A.P.A. SUMMARY The problem-oriented a p p r o a c h to record keeping developed by Lawrence Weed is having a significant impact on the practice of Psychiatry. In this system, the physician is required to identify list and number all the patient's psychiatric, social and physical problems. The problem list is kept a t the front of the record, much like a table of contents. All subsequent data including the clinician's plans and progress notes arc cross-indexed to the numbered problems. A plan for approaching each problem is constructed with thehclpof thelist of assetsand resources which include patient's existing or potential characterological strengths, vocational skills and talents, as well as resources and supportive factors within the family and community. At regular intervals progress notes are made which may be classified as subjeetive, objective or related to the treatment plan. This system is aimed at effective patient-care because the information can be easily retrievable and thus can be thoroughly analysed, correlated and synthesized into an ongoing tre.tment plan. Some problems posed by the system are discussed and the author offers a simple practical mode of recording. T H E NEED F O R CHANGE
T h e traditional m e t h o d of collecting, storing, and using the information a b o u t the patient, his illness and its t r e a t m e n t has got its own problems. (a) The hospital record oftenly contains comprehensive d a t a covering the patient's present illness, past history, family background, demographic information, etc. b u t effective and efficient utilisation of d a t a is impeded by its sheer volume a n d 'often b y ' poor legibility. (b) The traditional r o u t i n e of piling up reports from various sources, recording observations a n d d o c u m e n t i n g t r e a t m e n t procedures by various people in separate progress-notes results in a n accumulation of bulky records which can make it difficult to locate any pertinent information when required. Moreover, m a n y patients suffer from multiple problems, yet a systematic and up-to-date list of their problems is rarely available. THE P R O B L E M - O R I E N T E D APPROACH
For effective patient care, information must be easily retrievable so t h a t it can be analysed, correlated and synthesized i n t o "Consultant Psychiatrist, Royal Australia.
an ongoing t r e a t m e n t plan. T h i s is a c complished by the problem-oriented-method of codifying medical d a t a , developed by Lawrence WEED (1970), Professor of Medicine at the University of V e r m o n t in Burlington. R e c e n t studies by G r a n t a n d Maletzky (1972), Gilandas (1973), M a z u r (1974), R y b a c k (1974) a n d others show t h a t this system is applicable to psychiatry and in fact m a y be a major contribution to this discipline. Essentially, the problem oriented record (P.O.R.) requires the physician to identify, list a n d n u m b e r all the patient's psychiatric and social problems, as well as past a n d current physical ones. T h e p r o b l e m list is placed a t the front of the record, m u c h like a table of contents. All subsequent d a t a , including the clinician's plans, orders a n d progress notes a n d even t h e discharge summary are cross-indexed to the n u m b e r e d problems. T h list is then modified as problems change ; those which are resolved are marked accordingly and their corresponding numbers left unused thereafter. New problems are coded as they occur. T h e problem list functions as a n index
Park Psychiatric Hospital, Private Bay 3 P. O., Parkville.
H . D. C H O P R A
and allows the clinician to efficiently retrieve desired information. Moreover, the record serves as a repository for information a b o u t the course of treatment and outcome for each of the patient's problems. •Comparison between the T r a d i t i o n a l Psychiatric Record and Problem-Oriented Record (Ryback, 1974) :— The Traditional Record
findings from m e n t a l status and physical examinations, preliminary reports of labor a t o r y and psychological tests a n d observations of the patient's behaviour. 2. Problem Formulation T h e first step is to define and isolate problems. AH the team-members involved The Problem-Oriented Record (i) Data base content oriented,
(i) Data b ise discipline oriented. (ii) Patient's problems not well defined.
(ii) Patient's problem well defined,
(in) WV: i e.itereJ in record, treatment stated in general purpose terms, (iv) Patient's condition not systcmitically routinely assessed, (v) Treatments not routinely entered.
(iii) Treatment indicated
(vi) Important variables usually not specified,
(vi) Important variables within a treatment specified.
(vii) In discharge summary : — (a) course of treatment not adequately reported.
(vii) In discharge summary : (a) each problem separately reviewed and assessed. (4) after-care of each problem spelled out. (viii) The recording of all important events follows closely after the event.
(6) after-care not spelled out. (viii) The recording of events lags far behind events. (ix) Different elements of treatments not routinely entered or interrelated.
The Problem-Oriented Record (P.O.R.) contains four logical sequential sections :— (1) D a t a Base. (2) Problem List. (3) T r e a t m e n t Plans, and (4) "Follow u p " (Progress Notes). For an outline of the four basic sections, sec T a b l e I, (Ryback, 1974). l.Data
T h e initial data base is that irreducible minimum amount of information gathered on all patients, which has a probability of uncovering or screening the patient's major problems. This includes identifying data, chief complaints and history of present illness, personal history, family history, history of previous physical and emotional illnesses and treatments, significant social problems,
(iv) Patient's condition routinely assessed for each problem. (v) Treatments routinely entered for each problem.
(ix) All problems listed. All goals with regard to each problem listed. All treatments for each problem listed. Patient's response to treatment for each specific problem listed.
m u s t be able to identify problems to be entered on the Problem-list. * What is a problem ? T h e problem should be stated a t the h e a l t h care provider's level of understanding. (a) T h e problem can be aetiologic, diagnostic, or dynamic ; a b n o r m a l laboratory findings ; physiologic ; social or demograp h i c ; behavioural ; m e n t a l status ; or symptoms (refer Table I ) . (b) A problem may also be "incomplete d a t a - b a s e " if the information defined as necessary is missing, thus making evaluation a n d / o r treatment a problem for both the therapist and patient. (c) T h e problem defined may often need to be validated with the p a t i e n t , for example : the problem of being separated
P R O B L E M — O R I E N T E D APPROACH IN PSYCHIATRY T A B L E I — A n outline of the four problem
basic sections of the problem-oriented plans,
Chief Complaint Present Illness Psychosocial History Family History Physical Exam, Past Medical Hx., Review of Systems Mental Status Exam Psychological Testing Laboratory Studies
medical record : data
PROBLEMS (To be stated at the physician's level of understanding) Etiologic, diagnostic, dynamic—e.g., schizophrenia Abnormal laboratory finding—e.g., abnormal EEG Physiologic—intention tremor Social, demographic—separated Behavioural—temper tantrums Mental status—thought disorder, hallucinations Symptoms—insomnia The problems are numbered and the number is constant throughout the PROBLEM records, the list of problems become an Index —. >LIST to one patient's record
Sfiecijically State : PLANS(a) The protocol for 'Working-up each problem, the differential diagnosis, exactly what additional information is needed, how it is to be obtained, in what order. (A) The treatment, e.g. psychotherapy, behaviour therapy, ECT, psychophirmacology. What parameters necessary to judge efficacy. (c) What the patient is to be told.
or d i v o r c e d m a y b e c o n s i d e r e d a p r o b l e m by t h e m e n t a l h e a l t h c a r e p r o v i d e r , b u t t h e p a t i e n t m a y feel i t is t h e r e s o l u t i o n or a p r o b l e m for h i m . (d) F r o m a n o p e r a t i o n a l v i e w p o i n t , a p r o b l e m m a y be defined as " a n y t h i n g important e n o u g h to d o something a b o u t or for w h i c h s o m e t h i n g h a s b e e n d o n e " . («) A p r o b l e m c a n a l s o b e d e f i n e d a s something t h a t concerns the p a t i e n t , or the p h y s i c i a n or b o t h . (f) D i a g n o s i s m a y b e u s e d a s a p r o b l e m b u t n o t w i t h o u t f u r t h e r d e f i n i t i o n as t h e d i a g n o s t i c - n o m e n c l a t u r e is o f t e n sufficiently b r o a d t o b e useless for t r e a t m e n t p u r p o s e s .
Progress Motes. (Numbered and titled. Organised into subjecive or symptomatic data, objective data, assessment and plan). Flow Sheets (where applicable).
T h e h i g h e r l e v e l of a b s t r a c t i o n i n v o l v e d i n a diagnosis m a y on occasion be extremely useful as a p r o b l e m . W i t h o u t i t , t h e s a m e p r o b l e m list m a y b e d e f i n e d for a t h o u g h t d i s o r d e r a s for a n o r g a n i c b r a i n s y n d r o m e . F o r e x a m p l e : t h o u g h t blocking, loose associations a n d bizarre behaviour, a r c evident in both schizophrenia a n d tertiary syphilis ; yet one would not treat schizophrenia with Penicillin. (g) T h e p r o b l e m i d e n t i f i e d w i t h fall i n t o various categories. F r o m the view point o f n e e d of a c t i o n o r r e a d i n e s s for s o l u t i o n , a l l p r o b l e m s w i l l fall i n t o t w o c a t e g o r i e s : (i) Active Problem ( p r e s e n t , c u r r e n t , r e -
H. D . CHOPRA
quiring-action,needing immediate and ongoing m a n a g e m e n t or investigation), (ii) Inactive Problem.'! (past, solved, dorm a n t , requiring awareness because of a possibilit of reactivation or interproblem relationship and interaction). (h) T h e problems may also be classified according to the disciplines a n d realms of expertise, such as : (i) Medical (biological, organic, physical, somatic, constitutional, anatomic, physiological, a n d clinical pathological laboratory findings), (ii) Psychological (intellectual, emotional, behavioural, sensorial,psychiatric, endopsychic, intrapcrsonal, psychosomatic, a n d motivational), (iii) Sociological (interpersonal, demographic, social, economic, cultural, legal, vocational-educational a n d racial). * * What is a problem list ? Weed (1970) suggests t h a t the "first
page of a patient record should consist of a numbered problem list. I t is a 'table of contents' a i d an ' i ; d " x ' combined, and the care with which it is constructed determines the quality of t h e whole record. I n herent in t h e problem oriented a p p r o a c h to data organisation in t h e medical record is the necessity for completeness in the formulation of the: problem-list a .d careful analysis a n d follow through on each problem, as revealed iii the titled progress notes". Different workers have described their own comprehensive ways of p r e p a r i n g the 'problem-list'. 3. Treatment Plan : A plan for approaching each problem is constructed a n d cross-indexed b y n u m b e r to the problem. T h e plan m a y call for collection of further d a t a to clarify ambiguous p h e n o m e n a ; somatic pharmacological, psychological, activity or milieu t h e r a p y ; environmental manipulation ; or educating the patient to the management of his problems. T a b l e I I shows a sample of problem list a n d treatment plan.
TABLE II—Sample Problem List and Treatment Plan (GILANDAS, 1973) Problem number
Active and inactive problems
Depression (crying, not sociaUsing)
Paranoid ideation (people wish to harm her, threatens others)
Auditory hallucinations (voices of parents abusing her).
Vocational (lacks employment)
Problems 1, 2, 3—Medication : Largactil 50 mg. q.i.d. Elavil 25 mg. b.i.d. (psychiatrist). Notes are due each week. Problems 1, 2,—group therapy one hour per week (psychylogist). Notes due every two weeks. Problems 1, 2—occupational therapy. Craft work in a group two hours per week. Notes due e.ich week. Problem 1—industrial therapy. Serving meals in the cafeteria three hours a dayNotes due every two weeks. Problem 1—recreational therapy. Bowling twice a week and regular evening hospital activities. Notes due e. ch week. Problem 4—vocational counselling one hour per week (rehabilitation counsellor). Notes due every two weeks.
P R O B L E M — O R I E N T E D APPROACH I N PSYCHIATRY
4. Progress Notes : At regular intervals notes a r e inserted on t h e patient's progress. T h e notes a r e cross-indexed to t h e n u m b e r e d problems and m a y be structured according to whether they a r e subjective (the p a t i e n t ' s view of his problem), objective ( a c t u a l clinical findings and other aspects n o t i c e d by t h e clinician.), or related to the t r e a t m e n t p l a n (modifications or additions to t h e initial plan). T a b l e I I I shows a s a m p l e of progress record. T a b l e I V gives the format of t h e "Problem Sheet" used in a u t h o r ' s unit a t Royal Park Psychiatric Hospital, M e l b o u r n e , Australia. T h e medical officer presents
the detailed histor of the p a t i e n t a t the Te a m-me e ting (team comprises of t h e Consultant Psychiatrist, Medical Officers, Nursing Staff, Psychologist, Social Workei a n d O c c u p a t i o n a l Therapist) a n d t h e " P r o b l e m list" is p r e p a r e d w h i c h is reviewed every week. Action p l a n n e d for each p r o b l e m is assigned to t h e m e m b e r of t h e team concerned w h o takes action a n d reports back a t t h e next team-meeting. T h e "Problem-sheet" is always kept i n t h e front of t h e case-record a n d is used as a reference. No p a t i e n t is considered for discharge until all t h e problems h a v e been explored a n d a p p r o p r i a t e actions h a v e been taken.
T A B L E III—Sample Progress Record (GILANDAS, 1973) Date
Paranoid ideation 3 Auditory hallucinatioas 1 Depression
Notes (S, subjective.
O , objective. P, plan)
(S) States she is depressed. (O) Inappropriate affect a n d poor self concept. (P) Increase antidepressant medication if there is no change in the immediate future. (S) Does not verbalise paranoid ideas. (O) Remission (S) Denial of any hallucinations. (O) Remission —Psychiatrist. (S) Attends occupational therapy regularly but cries a lot. (O) Patient feels worthless a n d sorry for herself. (P) Needs constant instruction a n d supervision while doing crafts.—Occupational therapist. (S) Mixing with others upsets her. (O) I t is difficult for her to become involved socially because of her poor social skills. (P) T o work with her in a small group.—Recreational therapist. (S) Verbalises feelings of depression. (Ol Psychomotor retardation, flat affect with repressed hostility. (P) Encouraged to be more expressive in group therapy. (S) No longer believes people are against her. (O) Problem has been resolved.—Psychologist. (S) Feels incapable of working. (O) Presently too depressed to make realistic vocational plans. (P) Vocational tests to be given when patient stabilises. —Vocational Rehabilitation counsellor. (S) Says she enjoys working in the c fcteria. (Pi She should continue present v.ork .i-agnment. (O) This activity seems to diminish her depression.—Industrial therapist.
H. U. C H O P R A TABLE
Royal Park Psychiatric Hospital
Name : Mrs. O. W. Address :
Age : 57
Sex : F.
Marital Status : Married
PROBLEM S H E E T (To be filled in at Team Meeting) No.
Problem with duration
Assets and Resources
Episodes of depression and elation for 2 1/2 years, more frequent in last 10 months. Present episode of Mania.
a. Complete remission and adequate functioning for 14 years in the community. b. Good work record.
Thyrotoxicysis for 2 1/2 years.
No social supports
Action Planned (Assigned Staff) a. Use of a niaior tranquillizer. (Dr. P. P.)
Manic phase controlled with Haloperidol (40 mg. per dayl. Maintains improvement.
b. To be investigated for lithium carbonate treatment. (Dr. P.P.) Referral to General Put on Neomercazole Hospital for assessand periodic followment and manageup at the General ment. Hospital. (Dr. P. P.) T o arrange social Placement arranged in support (S.W.) the community and to be followed up at Royal Park Out-patient Clinic after discharge. Referred to Renal Unit Has been investiggtcd, (Dr. P. P.) not suitable candidate for lithium carbonate.
Advantages of Problem oriented record (Gilandas, 1973). T h e research of different workers suggests that the P . O . R . has the following advantages :— (i) Problem oriented approach encourages the use of sound logic in the t r e a t m e n t of patients, thus enhancing continuing education. Medical schools using the system as the basis of their curriculum have found that it facilitates meaningful interaction between clinical theory a n d practice. According to Mayou (1978) the problemsolving methods are likely to be much more effective t h a n convential teaching of psychiatry, (ii) Lot of valuable time can be saved
Action taken and outcome
when records are reviewed because information is easily retrieved. Communication with others about the patient is improved. Although the system doesn't require a computer, it anticipates and facilitates the computerisation of psychiatric records, Precise documentation allows more accurate clinical research. Case m a n a g e m e n t through structured d o c u m e n t a t i o n allows meaningful auditing and utilisation review. This is a significant a d v a n t a g e during a time when consumers increasingly demand accountability in terms of cost benefits from all supplying public services.
P R O B L E M — O R I E N T E D A P P R O A C H I N PSYCHIATRY
(vii) The P.O.R. functions as an excellent work sample of a physician which can be used by different examining bodies like Peer-review groups, (viii) The system's logic takes much of the "mystery" out of psychiatry and enables paraprofessionals to penetrate the rationale behind treatment and explore their own valuable contributions in the total management of the patient, (ix) Most importantly, patient care is improved. To think quantitatively about the needs of patients has qualitative implications for them. The stress upon the patient's involvement in his treatment together with education in the management of his problems is the basis for a viable therapeutic relationship. Critical Evaluation (Gilandas, 1973). The problem oriented system is not a panacea and as does every innovation, it has created some new problems. (i) The P.O.R. accommodates itself to any theoretical interpretation of human dysfunction but difficulties may arise when clinicians of radically different schools appraise each other's work. * Communication can be improved if therapists briefly specify their orientation and how they assess the data. (ii) Criticism has been experienced particularly by those committed to a Gestalt approach that the system fragments the patient and his problems. *The record itself can't fragment a person, only a clinician's fallible behaviour can do so. The Therapist must use his skills to integrate the information recorded, assessing and treating each problem in the con-
text of the other problems. (iii) The philosophy of viewing the patient merely as a list of problems may result in ignoring his strengths. *Mazur (1974) has added what he calls a vital balance approach to the system by including a patient's Assetlist. "This inregrates the catabolic vector of health promoting forces". The list of Assets and Resources includes the salient points of the patient's existing or potential characterologic strengths, vocational skills and talents, as well as resources and supportive factors within the family and community. ACKNOWLEDGEMENTS
The author is grateful to Health Commission of Victoria for the permission to publish this paper. Special thanks to Dr. M. Wellstead for presenting this paper on author's behalf at the Annual Conference of Indian Psychiatric Society held in Pune (January 1979).
REFERENCES GILANDAS, A. J . (1973). T h e Problem-Oriented Record in Psychiatry. A. N . Z. J o u r n a l of Psychiat., 7, 138. GRANT, R. & MALETZKY, B. (1972).
Approach to Psychiatric Record Keeping. Psychiatry in Medicine, 3, 119. MAZUR, W. P . (1974). T h e Problem-Oriented System in the Psychiatric Hospital : A Manual for Mental Health Professionals. California : Traincx Press. MAYOO, R. (1978). Psychiatric Decision Making by Medical Students. Brit. J . Psychiat., 132, 191. R Y B A C K . R . S . (1974). The Problem Oriented Record in Psychiatry and Mental Health Care. New York : Grune & Stratton, Inc. W E E D , L. (1970). Medical Records, Medical Education and Patient Care. The Press of Case Western Reserve University, Cleveland, Ohio.