Problem Oriented Medical Record CU 1 M 3

Problem Oriented Medical Record (CU 1 M 3)

Medical records are kept for every patient who steps through the door of a health care facility and who sees a health care provider. Every medical record provides evidence of the quality of patient care given. However, Not all records are alike, but there are some standard formats. This presentation is about one of those formats.

Medical Record Format: POMR P Problem O Oriented M Medical R Records

POMR - PROBLEM SOLVING ORIENTED MEDICAL RECORDS A method of recording data about the health status of a patient in a problemsolving methodology. All information is tied to a problem list.

POMR - PROBLEM SOLVING ORIENTED MEDICAL RECORDS The POMR format preserved the data in way that encourages the ongoing assessment and revision of the health care plan. It encourages a team approach to patient care.

POMR - PROBLEM SOLVING ORIENTED MEDICAL RECORDS The format of the POMR system varies from setting to setting, but the parts of the system are consistent. The POMR is divided into 4 parts: 1. Demographic/Database 2. Problem list 3. Plans of Action or Care Plan for each problem 4. Progress notes

PART 1: The POMR format includes developing a Demographics/DATA BASE of information

DATA COLLECTION A data base of information is collected before beginning the process of identifying the patient’s problems.

The database is the foundation for the patient’s plan of care. It is a collection of subjective and objective information about the patient, the medical history, allergies, medication regimen, physical and psychological findings and the present complaint. The database is usually completed by the physician.

The data base of information consists of everything available. This could include interviews with the patient, family or others, a health assessment, a physical examination of the patient, and/or various laboratory and other radiological tests. It is recommended that the data base of information be as complete as possible, and should be limited only by potential hazard, pain or discomfort to the patient, or excessive expense of diagnostic procedures.

The Database in POMR format includes completing an INTERVIEW

HISTORY The interview augmented by prior records, provides the patient’s history, including the reason for contact. DESCRIPTION (and more history) The interview also should include an identifying statement that is a descriptive profile of the person; a family illness history; a history of the current illness; a history of past illness; an account of the patient’s current health practices; and a review of body systems.

The database in the POMR format includes completing a Physical Examination

EXAMINATION EXTENT The physical examination or health assessment makes up a major part of the information in the database. The extent and depth of the examination vary from setting to setting and depend on the services offered and the condition of the patient.

PART 2: *NOT A “MASTER PROBLEM” The POMR format includes developing a Master Problem List

FORMULATION IDENTIFICATION The problem list is obtained from the baseline data and will be used to construct a care plan. Each problem/symptom that a patient reports and identifies represents a conclusion or decision resulting from examination, investigation, and analysis of the database.

Definitation Includes A problem is defined as anything that causes concern to the patient or to the caregiver, including physical abnormalities, psychological disturbance, and socioeconomic problems. The master problem list usually includes active, inactive, temporary, and potential problems.

INDEX The list serves as an index to the rest of the record and is arranged in five columns: Chronological List of Problems Onset Date (for each problem) Action Taken The Outcome (often its resolution) Date of Outcome

CHANGES Problems may be added, and intervention or plans for intervention may be changed; thus the status of each problem is available for the information of all members of the various professions involved in caring for the patient.

PART 3: The POMR format includes developing an Action Plan for each problem

Each separate problem is named and described. Each problem is routinely updated both in the plan and the progress notes.

POMR includes Progress Notes PART 4: Note: Vital signs may be part of the physical exam or the progress note In this part of the POMR medical record, the SOAP format is used. The SOAP format consists of information presented the following way: Subjective Data Objective Data Assessment Data/Diagnostic Data Plan of Action Data

There should be 1 SOAP notes for each problem. The Plan of Action should include a Discharge Summary

SUMMARY A discharge summary is formulated and written to cover each problem in the list and note whether is was resolved. This is the place in the SOAP note where unresolved problems are identified along with plans for dealing with the problem. The summary allows a review of all the problems initially identified and encourages continuity of care for the patient.

POMR ETIQUETTE Use proper abbreviations Every institution will have its own policy as to what abbreviations are acceptable and which are not. Documentation should be signed (manually or electronically) Use your first initial and last name A master list of individuals should be kept at each health care facility. Documentation should include the credentials of the person making the note.

ADVANTAGES OF POMR DOCUMENTATION Information about each problem is organized into specific categories that all caregivers can understand. Continuity of care is demonstrated by combining the Plan of Care and Progress Notes into a complete record of the care that is planned and the care that is delivered. Documentation is consistent. The POMR format is the most adaptable to the electronic medical record (EMR) The POMR format is the most efficient in documenting chronic disease.

DISADVANTAGES OF THE POMR DOCUMENTATION FORMAT Documentation is chronological rather than by priority. Both assessments and interventions may apply to more than 1 problem; therefore documentation especially using the SOAP format may be repetitious. Documentation using this methodology takes time.

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