Biomaterial Database

[A practical clinical record system for the general practitioner]. 1979

G J Pistorius

Owing to the multidisciplinary character of general practice, there is a great need for an effective and practical clinical record system for the family physician. The recording of clinical data of home visits and other visits places an extra burden on his record system. A practical system which tries to solve these and other problems is presented. A simplified form of Weed's Problem Orientated Medical Records (POMR) is incorporated in this system. The different components as well as the practical functioning of the system are described.

UI	MeSH Term	Description	Entries
D008499	Medical Records	Recording of pertinent information concerning patient's illness or illnesses.	Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D008501	Medical Records, Problem-Oriented	A system of record keeping in which a list of the patient's problems is made and all history, physical findings, laboratory data, etc. pertinent to each problem are placed under that heading.	Problem-Oriented Medical Records,Medical Record, Problem-Oriented,Medical Records, Problem Oriented,Record, Problem-Oriented Medical,Records, Problem-Oriented Medical,Medical Record, Problem Oriented,Problem Oriented Medical Records,Problem-Oriented Medical Record,Record, Problem Oriented Medical,Records, Problem Oriented Medical
D009774	Obstetrics	A medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium.
D009817	Office Management	Planning, organizing, and administering activities in an office.	Management, Office
D009934	Organization and Administration	The planning and managing of programs, services, and resources.	Administration,Administration and Organization,Administrative Technics,Administrative Techniques,Coordination, Administrative,Logistics,Supervision,Technics, Administrative,Techniques, Administrative,Administrative Coordination,Administrative Technic,Administrative Technique,Technic, Administrative,Technique, Administrative
D005194	Family Practice	A medical specialty concerned with the provision of continuing, comprehensive primary health care for the entire family.	Family Practices,Practice, Family,Practices, Family
D005568	Forms and Records Control	A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records.	Records Control,Forms Control,Records Management,Controls, Records,Management, Records,Records Controls