Problem-Oriented Medical record

problem-oriented medical record (POMR),

a method of recording data about the health status of a patient in a problem-solving system. The POMR preserves the data in an easily accessible way that encourages ongoing assessment and revision of the health care plan by all members of the health care team. The particular format of the system used varies from setting to setting, but the components of the method are similar. A data base is collected before beginning the process of identifying the patient's problems. The data base consists of all information available that contributes to this end, such as that collected in an interview with the patient and family or others, that from a health assessment or physical examination of the patient, and that from various laboratory and radiologic tests. It is recommended that the data base be as complete as possible, limited only by potential hazard, pain or discomfort to the patient, or excessive assumed expense of the diagnostic procedure. The interview, augmented by prior records, provides the patient's history, including the reason for contact; 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 systems. The physical examination or health assessment makes up the second major part of the data base. The extent and depth of the examination vary from setting to setting and depend on the services offered and the condition of the patient. The next section of the POMR is the master problem list. The formulation of the problems on the list is similar to the assessment phase of the nursing process. Each problem as identified represents a conclusion or a decision resulting from examination, investigation, and analysis of the data base. A problem is defined as anything that causes concern to the patient or to the caregiver, including physical abnormalities, psychologic disturbance, and socioeconomic problems. The master problem list usually includes active, inactive, temporary, and potential problems. The list serves as an index to the rest of the record and is arranged in five 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, 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. The third major section of the POMR is the initial plan, in which each separate problem is named and described, usually on 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, and palpation and from laboratory and radiologic tests; A, assessment of the problem that is an analysis of the subjective and objective data; and P, the plan, including further diagnostic work, therapy, and education or counseling. After an initial plan for each problem is formulated and recorded, the problems are followed in the progress notes by narrative notes in the SOAP format or by flow sheets showing the significant data in a tabular manner. A discharge summary is formulated and written, relating the overall 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.

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record [rek´ord]

1. a permanent or long-lasting account of something, such as in writing or on film.

2. in dentistry, a registration.

bibliographic record an index record standing for or representing a journal article, book, or other document.

Problem-Oriented record (Problem-Oriented Medical record) see problem-oriented record.

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medical

1. pertaining to or emanating from the study or discipline of medicine, in the context of veterinary science in veterinary medicine.

2. a class of diseases that are traditionally treated by medicines rather than by surgery.

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medical ecology

study of the environment and its relationship to a population of animals with respect to the effect of the environment on the diseases of the animals.

problem-oriented medical record

a standardized format for keeping clinical records in a problem-oriented case management system. An early decision is made on what is the nature of the patient's problem or problems and from then on the patient's status with respect to each problem is assessed daily. This has the undeniable advantage that the clinician does not lose sight of the objective with respect to the individual patient. Without this approach there is always an inclination for the clinician to attack the disease and place the patient on a lower priority. The attitude adopted as a result of this approach is very similar to the herd health approach in herd medicine—the objective is the farmer's survival, not the eradication of some bacteria.

medical records

the detailed records, made at the time, of the clinical, clinical pathology and pathology examinations and treatments of each patient, or patient group. The records have importance to the welfare of the patient, and to potential medical research and legal investigations, and to be worth their full value they must be made contemporaneously.

medical technologist

a qualified worker in a paramedical field such as laboratory scientist, veterinary nurse or livestock inspector.

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problem

a question to which there is no obvious, immediate answer; a question that requires some work done on it before a solution can be available.

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problem herds

herds which do not respond to the general control program for a particular disease and require special examination to elucidate the error and additional control measures to overcome it, e.g. a mastitis problem herd with a bacterially contaminated water supply.

problem knowledge coupler system

computer-assisted diagnosis system designed for use in human medicine; based on a special matching algorithm known as pattern recognition.

problem list

the list of problems to be overcome in a particular patient; in hospitals using a problem-oriented case management system.

problem name

a generally accepted, preferred name for a clinical sign, syndrome or other indicant such as a positive laboratory test, poor work or production performance or poor reproductive result.

problem-oriented case management

a system of managing patients based on the recognition of the patient's problems as targets for correction, planning the treatment program to achieve that, and assessing performance in terms of results with each of the problems and with the case overall. It is an excellent teaching procedure but is also helpful in maintaining the correct perspective in the patient's program.

problem-oriented diagnosis

a system of diagnosis that starts off with the cardinal sign presented by the patient and proceeds in steps to identify the body system involved, the part of the system affected, the nature of the lesion and the cause of the lesion.

problem-oriented medical record

see problem-oriented medical record.

problem solving

the basis of clinical veterinary (and most other) education; learning diagnosis by practicing resolving clinical problems—the essential problem being 'which disease is most likely to be the cause of the syndrome presented by this patient'.

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problem-oriented medical record

A medical record in which each Pt's condition or complaint is formally addressed; a POMR may be organized by the acronym of SOAP–subjective criteria, objective criteria, assessment, plan. Cf Hospital record, Medical record, SOAP.