By Ragnhild Bassøe Gundersen
The patient record was invented by Hippocrates. The purpose of the journal was to gather data to make predictions about the patients’ health. Journaling was resumed by Thomas Sydenham, who used them to describe a variety of diseases. The purpose of the patient record has since changed significantly. Today, all healthcare providers have an obligation to keep electronic patient records (EPR)
Satisfactory treatment and follow-up require a clear medical history. Anyone who examines and treats the patient must have an overview of the patient's illnesses and ailments within their medical field. The general practitioner (GP) must have an overview of all the patient's diseases. But the amount of data in today's EPR is huge, varied and unstructured.
Norwegian law states that the EHR should “… provide a clear and comprehensive representation of the patient's health condition so that it is easy for health professionals to get an overview of the patient's medical condition and potential further planned examinations and treatments.”.
In the chronological EPR, there are many journal notes dealing with a chronic condition. Journal notes are stored according to the date they were created. Thus journal notes about other diagnoses are often found in between journal notes concerning the chronic disease.
An overview of the patient’s medical history is only possible by reading multiple journal notes. Important information regarding the follow-up of the patient's chronic condition/conditions drowns in notes on short-term, self-limiting illness.
There is a great need for a structure in the EPR that provides a better overview than the structure found in chronological records. Such a structure is found in the Problem – oriented Electronic Record.