A medical record should be problem based and action oriented. I do not consider this a controversial statement.
Actions should be contextual and stakeholder associated and prioritised. It is natural that some desired actions will be mutually exclusive and that many actions will be variably desired.
This all sounds very obtuse. Carers, patients, healthcare providers, families and friends and society may all want mutually exclusive things. Autonomy is most important, but is not absolute.
Problems should be listed by the biopsychosocial frame and should be sorted by time and resolution as acute or chronic or recurrent, open or resolved, assigned or not, actionable or not and prioritised.
Holistic care requires a document that is complete and comprehensive and current to support it. An interactive document would be ideal.
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