Medical Record Format : "Comprehensive Problem-Based System”(CPBS)

----Ideologies and Styles of Medical Practice and Record----Symposium on Japanese Society of Internal Medicine Conference:Oct.2005(ed.Jan.2018)

Gifu University School of Medicine,Medical Education Development Center

KURIMOTO,Hidehiko M.D.

 

Introduction: The significance of Format

There is a fixed format for surgical records,echo observations,bone marrow

reports and others. If there is no format,each person should arbitrarily observe

and report it,so we can not get orderly knowledge. The format is "request

recognition of this object". Therefore,the format also implies "How much deep

recognition can be taken?", "How much deep recognition is sought?"

To be formed as a form,what has to be satisfied is “Terms are defined” and

”Writing rule is set". Unfortunately until today,as for the cardinal medical record

body,there has been no form suitable as a form.

It would not matter if you wrote whatever you wrote,so to speak,it would be a

rude note book despite the frame of medical care.

The CPBS has been practiced for 40 years with definitions and rules. It is the

form of the medical record itself.

Part 1 Basic Concept

Structure of CPBS Format

In order to elucidate the chaotic object,Descartes divided the subject into parts

and separately to solve,and devised a way to restore them (analysis and

synthesis). Even with the CPBS method,we extract individual diseases (problems)

from the patient and diagnose and reconstruct them to give a structure(problem

list) to the chaotic whole. (Fig. 1).

The work procedure of the entire process from the beginning to the end of this

method in actual medical practice of patients is as follows.

1) Collect basic materials.

2) Extract and name diseases (problems).

3) Create a problem list.

4) Describe each problem.

5) Manage the problem list.

Even if you see the work procedure immediately,you would not see significance

of this method without knowledge of the concept. Therefore,we explain the basic

concept of the CPBS in order.

Do not take CPBS as a subtype of L.L.Weed's POMR (Problem Oriented Medical

Record）,which is widely known currently,by the superficial resemblance between

both.

Even if they look alike on the surface,the content is completely different. If you

do not understand this difference,it will not be understood correctly. "Problems"

and "Basic Materials" are fundamental.

Basic Material (described later)

Materials that should be collected without preconception about objects are basic

material,consisting of "patient's descriptions of illnesses;PDI"/"past medical

information;PMI"/"present physical findings;PPF/present laboratory findings;PLF".

This is all information at the time of being. Lack of any pieces makes this raw

information insufficieant for analysis and extract of diseases.

Extraction and Discovery of Problems(illness)

We start works to discover the patient's illnesses from the obtained basic

information.

Think in order as follows.

1) How many illnesses are there?

2) What kind of illness is it?

3) What name should it be called by?

First,information on basic materials is sorted by illness and bundled. The

information collected in the way of PDI/PMI/PPF/PLF is classified for each illness.

Then,you can have groups bundled by an illness.

Each one corresponds to an illness (Figure 2). Unless you pathophysiologically

understand and interpret the dynamism of events regarding time axis/sites/

nature,you will not disringuish illnesses. Orderly knowledge and logical thinking

power are required. Each of the prepared "mass" is "one illness " and a name

will be given to each. This is the "problem" and the “diagnosis name” at that

time.

Naming the Problem

The naming of the bundled "mass" for each extracted illness is the most

appropriate at this point. That is the “disease name” ”diagnosis name” at this

time. You can call it only like this and can call it definitely like this. In other

words, "problem" is a medical abnormal condition that a doctor admits in a

patient. It is not an abstract disease concept,but specifically the patient's "illness

itself". So that,a problem is a “diagnosis name” at this time. Even though lung

cancer is said to be,it is not "lung cancer" only as a concept,but "this lung cancer

of this patient".

Generally in the early stages of diagnosis,an illness is not classified as a

classical disease name (dermatomyosytis/acute vertebritis/aplastic anemia etc.).

There are many problems that you could not name except for ones with such

broad quality as general symptoms/findings/conditions (acute lumbago/

hepatosplenomegaly/azotemia,etc.).

When the problem is named acute lumbago,even though this symptom and

other symptoms and findings form a “mass” of one illness,the essence of the

illness is thought acute lumbago,but not other miscelaneous symptoms or

findings. It is not yet known whether this acute lumbago is a spinal metastatic

cancer or a purulent vertebritis. But the diagnosis of acute lumbago is definitely

the illness of the patient. Other than that there is no suitable name.

Diagnostic work means departing from no name of illness,going through a wide

name,and searching a final specialized disease name.

Attributes of Problem

The problem named in this way has the following attributes as a name.

1. A noun which is a name.

Because it is a diagnosis name,it is obviously a name noun. At the outset of the

diagnosis a problem often is not with a classical disease name. Generally,broad

names such as abdominal pain/coma/pleural effusion/fever and so on are

the problems. At this time “pleural effusion” does not merely mean a finding. It

is the representative name of the illness.

2． Specific name without ambiguity.

Ambiguity ought to be rejected. For example,liver dysfunction is ambiguous. In

general,this term is refered to hyperAST or hyperALT-emia,but actually they do

not reflect liver cell function. It is not a sign of liver dysfunction. Signs of liver

dysfunction include jaundice/hypo-prothrombinemia/hyper-ammoniemia,etc. An

amount of serum AST or ALT reflects the quantity of destruction of liver cells.

You should avoid such mistaken term. That makes correct analysis and

interpretation impossible.

If you speak of AST or ALT in regard to liver disease,it is better to say hyper-

ALT-emia rather tham hyper-AST-emia,as AST can be a sign of muscle

destruction.

3. A name that is a fact.

“Suspect of” lung cancer is not a problem. Lung cancer can be listed as the first

of its differentials. It is not a fact. There is no disease, "●● suspect” disease. If

lung cancer is most likely,pulmonary nodule or mass is "the name of the illness”

of the patient at this time. It is a problem,that is the name of the fact that you

can only call the illness so.

4. Objects to deal with as a doctor.

Social events are patients' circumstances,not problems. For example,in

depression,unemployment/caring fatigue/child's illness are factors/triggers/risks

of depression. As if streptococcal pneumonia is a problem and streptococci are

not a problem,but an etiological microorganism. Wherever people reside,acute

leukemia is a problem to all people. But the living quarters are the living

environment of the ill person and are distinct from illnesses,and never written in

the problem list. If the target category is different,how to deal with it is different.

Doctors do not give money to patients,even if how much poor they are.

Information of circumstances is kept with a tag of social image and used.

To understand the concept of the problem,we shall explain supplements

indicating not problems.

Problem(illness) What is not a problem

１ Noun, an name of

disease

２ Specific name without

ambiguity

３ Fact name

４ Objects to deal with

as a doctor 

１ Gerund

２ Verbs

３ Descritption

４ Simple observations

５ Meaningless identification

1.Gerund

Arrhythmia episodes are cured each time,but the disease "paroxysmal

arrhythmia" has not cured. Kinds of gerund,seizures/exacerbations/

accumulates,are not problem names. A problem must be metastatic brain

tumor,not brain metastasis.

2. Verbs.

The kind of "R/O (exclusion)" is not a problem.

3．Description.

Description of "There was" such as "past history of ~" is not a problem.

4. Simple observation.

"Neutrophils reduction" "Serum low Na” is the finding of the test results and not

the name of disease. "Neutropenia" "Hypo-natoremia" is the name of disease

typified by its findings. There will be other abnormalities,but they are the best to

represent themselves to call patient's illness.

5．Meaningless identification.

The name of illness must express essence. Now,supposing knee

osteoarthropathy on the left side,is the problem "left knee osteoarthropathy"?

Then,when it occurs on the right,is this time problem "right knee

osteoarthropathy"? Right or left is not related to essence of this degenerative

joint disease. The patient's illness, "knee osteoarthropathy", is now on either side

at this time.

A stone which had been present in a renal calyx was down to the ureter

yesterday,and today is seen in the bladder. We do not recognize the nature of the

disease by the position of the stone at the time.

There are cases designation of the site is significant. Right epigastric pain/right

lower abdominal pain is a sample. The biggest, "head" ache/"chest" pain is the

site of pain.

Set called Problem

The problem is named. The named problem is a collection of illnesses called by

that name (Fig3).

The patient 's illness is always in the set. If "diabetes" is a problem,a patient's

illness is in collective "diabetes”. Even if it is not a classical disease name,even for

the problem "acute lumbago" represented with a symptom,even "chronic

thrombocytopenia” expressed by a finding,the illness of the patient is in that set.

The diagnostic work is a task of reworking the problem name to a more specific

disease name. In other words,we proceed naming from the initial set to that

subset. The set goes directly down and is divided into different exclusive subsets.

The patient's illness exists in any of them. It is also in one of the subsets of that

subset (Fig4). Thus, the subset is replaced by the more specific name of the

specific set and the diagnosis will go to the final name of the disease.

Problem List

There are not only one illness detected from information materials. At the age

of today,there are multiple illnesses in one patient.

The list of the problems is "Problem List". Since it is a list,there must be a rule

as a list.

According to L.L.Weed's POMR widely known,miscelaneous things are written

as “Problem”,either “disease”/“simple observation”/”symptom”/”past disease"/

"social affair”/”social situation”. And,there is no order in "number" and "date". It

is about a cluttered private memo of the examination items. And concerning with

the conclusion we discussed (diagnosis) ,a patient's illness is not written

anywhere. In short there is no conclusion. No diagnosis (Figure 5).

“Problem List” of CPBS is a list of diseases of conclusive diagnoses.

Writing Rule of Problem List

１ Register all problems.

２ Number the problems. 

３ Number in order of registration/occurrence.

(number not change from beginning to end).

４ Enter the date of registration.

５ Show the development of the problems.

There are the following rules.

1. Register all problems. No need to say that proper treatment can not be done

without knowing all diseases.

2. Register by attaching a number (#) to the problem. That number does not

change from beginning to end like registration of family menbers in the ledger.

3.The number is registered in order of registration. If some are of the same

registration date,they shall be in the order of occuerrence.

It should be noticed that it is not in the order of importance. List of importance

order is,for example,#1 dissected aneurysm/#2 hypertension/#3 diabetes. If a

cerebral infarct suddenly occured,it will be rewritten as #1 cerebral infarct.

Furthermore,if tonight with severe pneumonia,#1 will be again rewritten as acute

pneumonia. Every time the list is rewritten into a confused description.

On the contrary,the list of occurrence order is #1 hypertension/#2 diabetes/

#3 dissecting aneurysm/#4 cerebral infarct/#5 acute pneumonia.

This is firm registration,no loose. In this way,we can consistently describe the

problems over time and space to make continuity of medical care possible.

4. Enter the date of registration [brackets]. Be aware that it is the date of

registration and not the date of occurrence. This day [brackets],the doctor

declared the disease. Waiting for the doctor's recognition,it becomes a medical

treatment subject. No recognition,no existence.

5. Show the up-dated name of a problem by →. (Described later)

The problem list is renewed with the updated name of the problem. Show the

name with the registered date.

The problem list is always with the patient in this way,and functions as a frame

of medical practice. Looking at the list,you can see the history and current state

of the patient's disorders at once and clearly (FIG. 6).

Description for Each Problem

We shall return to the classification of the basic material.

Prolem is one illness. There are,as one illness,each past/present/future.

It should be possible to describe them for each. Groups of information for each

illness are packed into "PP”;to the present/"PF”;at present/"C”;consideration/

”P”;plan.

To the present

PP(from past to

present）

Present time

PF(present findings）

Consideration

C(consideration

）

Plan

P(Plan)

Patient's

description of

illnesses (PDI)

Past medical

information (PMI)

Present physical

findings(PPF)

Presenr laboratory

findings(PLF)

Analysis/interpre

-

tation/policy/aim

Plan

Significant information in the document belongs to any illness. Each information

has to be sorted to any illness one by one. This importance is explained..

Problem list: #1 hypertension/#2 diabetes/#3 lower leg cellulitis. There is urine

protein(2+) seen in this patient. Which problem will you write this proteinuria in?

＃１ hypertension ＃２ diabetes ＃３ lower leg cellulitis ＃４ proteinuria

(a) PF：ＵＰ 2+ ―――― ―――――― ――――

(b) ――――― PF：ＵＰ 2+ ―――――― ――――

(c) ―――― ―――― PF：ＵＰ 2+ ――――

(d) ――――― ―――― ―――――― PF：ＵＰ 2+

The renal lesion of this proteinuria is; in(a) hypertensive nephrosclerosis/in

(b)diabetic glomerulopathy/in(c)temporary focal glomerulonephritis. It is

automatically shown in the writing. In case not related to any one, #4

proteinuria rises as another problem. If proteinuria is quite massive in(b),a new

problem is made independent as diabetic nephropathy. You are requested to do

classify every thing. In response to this request we are able to gain deep

understanding.

The factual materials that serve as the basis of consideration C are in PP and PF.

PP and PF are a fact description. Before we think about,we have to know what

kind of the things should be known in order to know about the things.

Site/range/shape/cause/risk/origin/type/classification/function/degree/progress/

course/complications/prediction/prognosis,etc. We will hold those empty frames

of the things that should be known and then fill out the blanks. Since the

consideration is a consideration of this patient's problem to the last,reference or

text quotation on general is not applicable.

Plan P is divided into three parts: diagnosis Dx/treatment Tx/explanation-

persuasion (content) Ex. A plan is a future act specifying the date/time/person/

place/method,etc. to be followed. Since the category is different,not aim/

purpose/motive,a description with A and P together; A / P is impossible.

Of the problem the past/the current state/the object of the future plans are

described in the format.

#1 X

PP brief and compact summary of PDI/PMI

PF brief and compact summary of PPF/PLF

C Consideration (evidence based on PP/PF)

P Dx/Tx/Ex

Progress Record

After creating a problem list,this is the core frame of medical practice. Practice

is described day and night for each turn at either hospitalization or clinic.

Describe the progress separately for each problem. (Fig. 7).

#1 X

PP symptoms/course from previous time to present

PF previous lab.results/present physical findings

C consideration at this time

P plans at this time

*1 The common general health indexes(appetite/stools/sleep/menses,etc.) is

mentioned in the most important problem at that time,that is, the most

important is shown by this way.

*2 Plan P,particularly the treatment plans,can significantly affect all the problems.

It may be written together in the most important problem. It also means the

attitude of unconcern prohibited.

If you continue medical practice for a long time,you will frequently encounter

temporary mild problems. Do not give them an official number. Instead,treat it

as a problem with provisional number #a/#b/#c. The official number is a

permanent serial number,but this a/b/c can be repeated any number of times.

The provisional problem may be the followings.

1. Transient mild

#a cold

2. The basic material is inadequate and it is not possible to decide on the order

of occurrence with official numbers

#a edema/#b antinuclear antibodiemia/#c interstitial pneumonitis

3. Not yet decided whether it is an actual disease

＃a hyper-ALT-emina

Development of Poblem

A problem is seldom named a classical disease name (sarcoidosis/sclerosing

cholangitis/interstitial urocystitis,etc) from the beginning. A problem can be

named only a symptom name (headache/insomnia/arthralgia,etc.),findings

name(cardiac murumur/anemia/ascites,etc) or state name (delirium/

hypercalcemia/bradycardia-hypotension syndrome,etc.).

Nevertheless,the best name at this point has to be given to the problem. It is

important to note that the name that became a problem once is a diagnosis

name called by borrowing the name of symptom,etc. Initially it can only be called

a nonspecific broad name. From this beginning,diagnotic works begin to gain the

more specified name. Diagnosis is nothing short of going for a specific name. It

is as if opening a big box and taking another box inside,opening it further and

finally finding the object you are looking for. This is called development of a

problem.

Developement has 7 types.

1. Progress: The name became more specific. This is the basis of development.

There are 2 subtypes.

1-1； Deepening recognition

Example #1 pancytopenia → myelodysplastic syndrome

1-2： 1-2: Identification the cause

Example # 1 acute pneumonia → acute staphylococcal pneumonia

To an inevitable cause, ( ) is used. It is limited to the following. Example a

microorganisms/drugs,etc. #1 hypersensitivity pneumonitis → hypersensitivity

pneumonitis (drug). Example b direct causal relationship with other problems.

#1 nephrotic syndrome (#2)/#2 lupus erythematosus.

2. Inclusion: A problem thought initially as separate turned out to be a part of

another problem.

Example #1 acute low back pain → acute staphylococcal spondylitis/#2 fever

→ (inclusion) #1 <finished>

3.Transition:

3-1; A problem changed the nature to another and no original disease anymore.

Example #1 acute renal failure → (transition) chronic renal failure.

3-2;It became markedly different as a disease.

Example #1 acute leukemia → (transition) acute leukemia (allogeneic

marrow transplantation)

4. Correction:

Example #1 nasal hemorrhage → (correction) hematoemesis

5. Cancellation: Mistaken a disease existing.

Example #1 lung cancer → cancellation<finished>

6. Termination: Not a cure,but the problem no longer exists. It often occurs in

surgery or accidental trauma. Meaningful reason is shown in ( ).

Example #1 osteogenic sarcoma → termination (trauma amputation) <finished>

7. Cure: Meaningful reason is shown in ( ).

Example #1 ulcerative colitis → cure (total colectomy) <finished>

In case that the problem became no longer to exist, it is indicated as

<finished>.

Here, additional explanation is necessary about the development rule. There are

two different categories of the names. There is an inclusion relation in the same

category.

ａ．Pathological-morphological category

arthritis ⊃ chronic arthritis ⊃ chronic polyarthritis

pulmonary mass ⊃ pulmonary carcinoma ⊃ pulmonary adenocarcinoma

ｂ．Physiological-functional category

hypoglycemia ⊃ hyperinsulinemic hypoglycemia

azotemia ⊃ renal failure ⊃ uremia

One illness has both categories simultaneously. Chronic nephritis presents renal

failure in some patients,but not in some others and so on. Fundamentally gravest

for people is a physiological-functional category state of health/illness/death.

Since it threatened,we pursue and treat pathological-morphologic categories of

diseases.

8. How to treat two categories.

8-1; In case that a disease of pathological-morphilogical category

autonomously describes the physiological-functional category state,

no need to arrange the problem separate and make progress in the same

problem. Example #1 hyperthyroidism → Graves' disease

8-2; If it does not necessarily imply the physiological state,arrange both

problems and show the causal relationship between them.

Example #1 hypoglycemic coma (# 2) /#2 insulinoma

Part 2 CPBS : procedure thinking

Where the concept of the CPBS is understood,we shall return to the actual

procedure.

1) Collect basic materials.

2) Extract and explain diseases (problems).

3) Create a problem list.

4) Describe each problem.

5) Manage the problem list.

2) to 5) are the actual after collecting the basic materials and already explained

in the previous chapter. We will describe the basic material collection(1) of the

former stage.

Basic Material

When you consider the basic materials chronologically,its meaning is easy to

understand. Patients bear informstion from the past,their description of the

illnesses(PDI) and past medical information kept in the medical facilities(PMI).

Doctors begin to observe the patients now. Information obtained by current

observation is the present physical and laboratory findings (PPF and PLF).

             Basic Materials

PP; from past to present P; present

patient's description of

illnesses(PDI)

past medical information(PMI)

present physical findings(PPF)

present lab findings(PLF)

what patients bear what doctors currently obtain

a) Patient's description of the illnesses;

current medical history/past history/ family history/social image of the life.

The current medical history is the historical description of the patient's present

illnesses obtained by an inquiry interview. It is not a comment by a doctor. We

have to distinguish strictly between a past illness and an existing illness. A past

illness is no longer existing. An existing illness started in the past and is still

continuously present,not finished(Fig8).

“hypertension” and “diabetes” in patients with acute myocardial infarct are

clearly existing. They should not be treated as non-existing past illnesses. The

current medical history starts from existing illnesses and come to present. It is

not known at the time of basic data collection whether this time incident is

related to the existing disease or a new matter.

b) Physical Finding

Routine items are printed and requested. As an illness of a patient is yet

unknown,consistent findings ought to be taken from all patients. The findings

which have not been taken are to be shown not taken. Somewhat loose physical

examination is not permitted. The ability to take accurate findings is severely

trained.

c) Routine Laboratory Findings ;

Packages for various tests that are sensitive/simple/fast/inexpensive,even if less

specific. The basic tests must be taken correctly and interpreted by everyone.

d) Past materials kept in the medical facilities;

medical examinations/medical records/referral letters/nursing records/picture/

pathology, etc.

These are doctor's records that the medical facilities have held,that contrast with

patient's description of illnesses.

From this basic materials,positive and negative information that contribute to

the analysis is extracted and organized chronologically. It is not easy to organize

the information of the past effectively. There must be no redundancy and neglect

to enter. It is compared to an archaeological museum that arranges excavation

materials by category in time series.

From here the brain work of the problem discovery and description begins as

you saw in the previous chapter. By describing each problem,the information is

transformed into knowledge about the patient's illness.

Problm List is displayed at the top of daily record as a frame of medical practice.

The list is "Doctor's declaration" [date] to say "These diseases [problem]"

"Occurred in this order" [#number] and "Now this” [date]".

Conclusion:Significance of Medical Record Format

The format of the medical record body has at least the general significance of

the format.

1 It expresses quality.

2 Objectify thinking acts.

3 Guarantee the required level.

4 Train thoughts as required by the format.

Bad format allows poor thinking acts and,of course,good format promotes good

thinking acts. Without time nobody could write down precisely. However,even

without time to write we would like to see if the thinking acts satisfy the format.

Finally,we show that the problem list is at the heart of the practice and

functions. The problem list exhibits exactly,correctly and concisely the long

medical history of one single person who has lived such a long time and his/her

current medical state.

There is no doubt of the clinical significance that the problem list stays together

with the patient always,any time and anywhere.

CPBS from the time of birth

Problem list:

#1 exanthema subitum [registration date] → cure [registration date] <finished>

#2 HAV acute hapatitis [registration date]→ cure [registration date] <finished>

#3 acute appendisitis [registration date]

→ cure(appendectomy) [registration date] <finished>

#4 diabetes mellitus[registration date]

#5 acute pneumonia [registration date] → acute pneumococcal pneumonia

[registration date] →cure [registration date] <finished>

#6 monoclonal gammopathy [registration date]

#7 cerebral infarct[registration date] → cure[registration date] <finished>

#8 post-cerebral infarct aphasia [registration date]

#9 prostatic carcinoma[registration date]

#10 cerebral infarct[registration date]

CPBS from a certain point in time

Past illness:exanthema subitum[year]/HAV acute hepatitis [year]/

acute appendisitis [year]

Problem list:

＃1 diabetes mellitus[registration date]

＃2 acute pneumonia [registration date] → acute pneumococcal pneumonia

[registration date] →cure [registration date] <finished>

＃3 monoclonal gammopathy [registration date]

＃5 cerebral infarct[registration date] → cure[registration date] <finished>

#6 post-cerebral infarct aphasia [registration date]

#7 prostatic carcinoma[registration date]

#8 cerebral infarct[registration date]

(end)