Problem oriented medical record

Problem Oriented Medical records
A basic introduction
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Definition
• Problem-oriented medical record (POMR)
• A method of recording data about the health
status of a patient in a problem-solving system, in
an easily accessible way that encourages ongoing
assessment and revision of the healthcare plan by
every actor in the heath-care team.
• Is a comprehensive approach that Dr. Lawrence
Weed began using in the late 1950s.

What POMR Specifically addresses
• Managing chronic illness often involves multiple interventions that require adjustment over time,
rather than a single treatment that results in cure/resolution. This requires tracking of physiologic
variables and medical interventions over time.
• Chronic care of medically complex patients, especially those with multi-morbidity, requires
coordination of care among multiple clinicians at multiple sites over time.
• For the many people suffering from multi-morbidity, chronic medical problems and their
associated interventions often interact. This makes it particularly important that care be
individualized, and carefully tracked over time.
• Enabling patient awareness, participation, and commitment is essential, with the Weeds noting
that “unavoidable complexity must somehow be made manageable by patients who need to cope
with what is happening to their own bodies and minds.”
• Patient care – and hence the charting of medical data — must be oriented towards a single
purpose: individualized medical problem solving for unique patients.
In other words, “the longitudinal, comprehensive, person-
centered, individualized, collaborative care of the medically
complex patient” is a fundamental base scenario around which
healthcare and healthcare information systems should be
designed upon.

POMR-Flow

Core components
• Core components for the POMR:
– A defined database of information, to store the relevant
information(History, Physical Exam and Laboratory Data) that
has been gathered;
– A problem list, with problems defined in terms of the patient’s
needs;
– Initial Plans of action for each problem, developed in light of
the other problems;
– Progress notes on each problem, which document the process
of following up, including gathering of feedback and adjusting
the plan over time.
– Final Progress Note or Discharge Summary, which document
the process of following up, including gathering of feedback and
adjusting the plan over time.

Step # 1
• Start off by obtaining information about the potential
hazard, pain or discomfort to the patient
• Augment the information by:
– recording prior records,
– providing the patient's history,
– including the reason for contact;
– a descriptive profile of the person;
– any family illness history;
– a history of the current illness;
– any history of past illness;
– an account of the patient's current health practices;
– and a review of systems.
• Many hospitals include certain routine laboratory studies
(CBC, SMAC, EKG, chest x-ray, urinalysis, etc.) for each patient
admitted. If these are available to the admitting physician,
they are to be included in the initial steps.

Step # 2
• The next section of the POMR is the master problem list.
• A problem is defined as ”anything that causes concern to the patient or to
the caregiver, including physical abnormalities, psychological disturbance, and socio-
economic problems”. Problems are either active or inactive (inactive problems are
usually prior, resolved medical or surgical illnesses that are still important to be
remembered).
• The master problem list usually includes active, inactive, temporary, and potential pr
oblems including psychosocial problems.
• The list serves as an index to the rest of the record and is arranged in columns:
• a chronologic list of problems,
• the date of each problem's onset,
• the action taken,
• the outcome (often its resolution), and
• the date of the outcome.
• Problems may be added, intervention or plans for intervention may be changed.
• Each problem as identified represents a conclusion or a decision resulting from exa
mination, investigation, and analysis of the data base.
These data obtained from step 1 and 2 are essential for the practitioner to understand
the patient’s ability to cope with medical problems and to work realistically with the
patient in setting goals and planning for diagnosis and management.

Step # 3
• A physical examination or health assessment
of the patient.
• The extent and depth of the examination will
vary from setting to setting and depend on
the services offered at the facility and the
condition of the patient.

Step # 4
• Record the initial plan, in which each separate
problem is named and described.
• Usually done in the progress note in a SOAP
format:
• S, subjective data from the patient's point of view;
• O, the objective data acquired
by inspection, percussion, auscultation, palpation,
from laboratory and radiologic tests;
• A, assessment of the problem that is an analysis of the subjectiv
e and objective data and
• P, the plan, including further diagnostic work
therapy and education or counseling.

Finally
• After an initial plan for each problem is formulated and recorded,
the problems are followed in the progress notes by narrative note
s in the SOAP format or by flow sheets showing the significant
data in a easy to understand manner.
• A discharge summary is formulated and written, relating the over
all assessment of progress during treatment and the plans for
follow-up or referral.
• The summary allows a review of all the problems initially
identified and encourages continuity of care for the patient.
Without well-structured progress notes, clinicians can easily fail to
recognize trends and correlations in data, lose track of significant
test results, fail to consider interactions among multiple problems,
or fail to coordinate their activities with other practitioners. These
failings occur particularly with chronic illness

Are there any drawbacks using the
POMR?
• Insufficient time allotted to provide care to each
patient. Even with a smart POMR-ready EHR system
that properly organized information by problem, I’d
expect each encounter would require at least 30
minutes of physician time, if not much more.
• Insufficient financial incentives to practice
comprehensive, person-centered, individualized,
collaborative care over time. Unless you focus on a
population of high utilizers with “ambulatory sensitive
conditions,” a POMR approach seems unlikely to
reduce hospital and ED utilization enough to keep the
ACOs happy.

References
• http://medical-
dictionary.thefreedictionary.com/problem-
oriented+medical+record
• http://thehealthcareblog.com/blog/2013/05/
10/the-problem-oriented-medical-record/

Problem oriented medical record

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