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A Problem Oriented Medical Record (POMR) is a way of recording patient health information in a way that’s easy for physicians to read and revise. The basic idea of POMR is to equip doctors with the ability to understand the patient’s medical history. Since its introduction to the medical world in 1968, POMR has been an important resource for supporting patients with chronic illnesses and other complicated medical problems. However, POMR was also the world’s first electronic health record (EHR). The patient will start by telling the doctor or nurse of their symptoms and other issues. In turn, the nurse will or assistant will input the information into an I.B.M. Ramac 305 (New York Times). Where & How Did POMR Start?POMR was introduced in 1968 by Dr. Lawrence Weed. Dr. Weed developed POMR so that “medical students and practitioners could function in a structured, rigorous way more like that of workers in the scientific community” (NCBI). In other words, Dr. Weed intended POMR to serve as a way to standardize the way physicians record and organize patient information. Before POMR, physicians were documenting patient histories in less efficient ways. For example, they would document medical information by source, e.g., x-ray reports in an x-ray section, and lab reports in a section about lab reports, and so on. Build on the Time & Cost Savings Advantages of POMR through EHR/EMR:
However, Dr. Weed opted to organize information in terms of responding to patient problems. So under POMR, Dr. Weed recorded the patient’s information through 5 components:
Since implementing POMR, the health care community also began using SOAP Notes. Like POMR, a SOAP Note is a standardized documentation method, but between different health care providers or departments working with the same patient. The SOAP Note comprises of 4 parts:
This component outlines the patient’s main complaint. The physician will also record an HPI (history of present illness), which the patient will describe to the physician. At this point, the physician will listen to the patient for many key details, including: – Negative/Relevant Symptoms – Surgical History – Family Medical History – Current Medications – Drug, Alcohol, & Caffeine Use – Other Factors (e.g., blood pressure)
The physician examines the patient’s basic attributes, like weight, vital signs, and measurements. The physician will also note results from lab and diagnostic tests.
At this stage, the physician will outline their observations of the patient’s symptoms and their diagnoses. In a hospital environment with an admitted patient, the doctor will take note of how the patient is progressing following treatment.
Finally, the physician will state the next steps for the patient. This step may include assigning treatments, requesting additional tests, or referrals to specialists. What’s the Benefit of POMR?POMR was the medical community’s first foray into standardizing patient records and storing it in an electronic format. Since then, POMR has enabled physicians to save time as well as raise the quality of patient care and improve patient satisfaction. For example, with POMR, physicians, and nurses in different departments of the same hospital got a standardized method of reading and updating patient information. Likewise, other clinics and outside consultants could also view the same information in the same way. However, in the decades following POMR’s introduction, the medical community has shifted to adopting EHR systems that run on EHR/ EMR Cloud Hosting systems. Arguably, the most significant shift to EHR happened following the introduction of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. According to the Centers for Disease Control & Prevention (CDC), 80% of physicians in the US are using a certified EHR system. Today, you can leverage — and expand — on the benefits of POMR through a well-optimized and configured EHR system.
How You Can Apply POMR TodayYou can implement the POMR approach by using fully-defined templates in EHR. You can set standardized templates for every kind of treatment and patient visit. Through these templates, you can enable your physicians to add or update patient records with incredible granularity. For example, in addition to the information you could record under POMR, correctly configured EHRs let you record data from medical devices. In turn, you can set specific fields in the template to record device data in a format that makes sense to other medical staff. In comparison to POMR, physicians can share information more seamlessly and quickly using EHR systems. As a result, hospitals have been able to cut the time physicians spend opening patient records and, in turn, devote more time to patient care. We cover this in detail in one of our earlier blogs about the Pros and Cons of Electronic Medical Records. Generate more time for patient care by eliminating slow EHR loading speed and information errors by properly configuring your EHR system. Contact True North today. What are the methods of organizing a medical record?Filing your personal medical records in chronological order will be most beneficial to you. To do so, file all personal medical information from oldest to most current medical events, doctor's, laboratory, clinic, or hospital visits.
What is one of the most widely used methods of charting?Key Takeaways
A Gantt chart is a visualization that helps in scheduling, managing, and monitoring specific tasks and resources in a project. It consists of a list of tasks and bars depicting each task's progress. It's the most widely used chart in project management.
What is the most common document that will be a part of the patient chart?Common Types of Documentation
Common formats used to document patient care include charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, patient discharge summaries, and Minimum Data Set (MDS) charting.
What is the golden rule of chart documentation?Remember the Golden Rule: If it isn't documented, then it wasn't performed. Reviewers do not know the services provided if there is no documentation. You are paid for what you document, not what you did.
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