Until the mid-1970s, the purpose of medical documentation was to remind doctors of the patient’s database and to provide a means of communication with other care-providers. The patient’s record was oriented to diagnoses, whether certain or suspected. Doctors were not required to record the process of reasoning that led to their decisions, and the medical record did not reflect doubts, deliberations, or explicit consideration of alternative management options.

The POR differs from the traditional record in several aspects. First, it is oriented to problems, rather than diagnoses. A problem is defined as any symptom (e.g., epigastric pain), finding (pulmonary infiltrate, fasting blood sugar 180 mg/dl), established diagnosis (bacterial endocarditis, Strept viridans), mental condition (depression), social state (on welfare), or treatment that may affect the health of the patient (anticoagulation). A problem is expected to be certain and not suspected: the problem of a patient who consults a doctor because of epigastric pain would be formulated as “epigastric pain” and not as “suspected peptic ulcer.” On the other hand, just as a problem is not expected to consist of a diagnostic hypothesis , which is more than what is certain, so also, it is not expected to consist of what is less than certain: for example, if subsequent endoscopy reveals a duodenal ulcer, then the patient’s problem “epigastric pain” would be updated to state “duodenal ulcer.”

The problem list has contributed to clinical reasoning by promoting a taxonomy that clearly distinguishes between the unresolved and ambiguous, on the one hand, and between the diagnosed and clearly defined, on the other [3]. The list appears at the beginning of the patient’s record, and is intended to reflect the knowledge about the patient when last seen. It serves as the point of departure for the summary that follows the recorded patient’s history and physical findings. This summary includes, for each of the patient’s identified problems, the reported data, the objective findings, the doctor’s assessment, and the doctor’s plan for future management. At each subsequent visit, the problem list would be reexamined with a view to ascertaining the problems that were resolved, adding newly identified problems, following-up the unresolved problems and response to treatment of the diagnosed problems. The problem list is expected to be continuously updated as more data become available.

A second difference between the traditional record and the POR is the way the patient’s history is presented. The traditional presentation of the history used to adhere to a chronological sequence. Such a presentation was difficult to follow in patients with more than one problem. For example, the presentation of the evolution of the symptoms of a patient with heart disease and rheumatoid arthritis was confusing if both diseases developed simultaneously. In such cases, the POR requires editing the patient’s history with a view to sorting out and presenting separately the manifestations of each of the patients’ problems.