IVMS ICM-Problem Orientated Medical Record (POMR)


Published on

IVMS ICM-Problem Orientated Medical Record (POMR)

1 Like
  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

IVMS ICM-Problem Orientated Medical Record (POMR)

  1. 1. Problem Orientated Medical Record (POMR) Marc Imhotep Cray, M.D. For: IVMS ICM-Physical Diagnosis PowerPoints and Notes Source/modified from: http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/subint/pomrfinal.htm Problem Orientated Medical Record (POMR)The POMR as initially defined by Lawrence Weed, MD, is the official method of record keepinguse by most medical centers and thus in most undergraduate medical schools. Manyphysicians object to its use for various reasons - it is too cumbersome, inhibits datasynthesis, results in lengthy progress notes, etc. However, the proper use of the POMR doesjust the opposite and results in concise, complete and accurate record keeping. A briefoverview of the salient features of the POMR will be helpful.The basic components of the POMR are: 1. Data Base - History, Physical Exam and Laboratory Data 2. Complete Problem List 3. Initial Plans 4. Daily Progress Note 5. Final Progress Note or Discharge SummaryNote: 1, 2 and 3 above must be completed by the admitting physician.DATABASEThe importance of the Data Base is obvious and must include a complete history and physicalexam. 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 admittingphysician, they are to be included in the initial data base along with a history and physical. Asadditional information is collected it is added to the Data Base.COMPLETE PROBLEM LISTAfter the admitting physician performs the history and physical, reviews the basic laboratorydata and records the data base, the Problem List is constructed and recorded. Theconstruction of a Problem List is the initial step (for the next step, see number 3 - InitialPlans) of what physicians "really do". That is, once they have seen the patient, physicians IVMS-ICM/MIC/10/11 Problem Orientated Medical Record (POMR)
  2. 2. think about and define "what is wrong with the patient" or "what are this patients problems."Problems are either active or inactive (inactive problems are usually prior, resolved medicalor surgical illnesses that are still important to be remembered). Dr. Weed had defined anactive problem as anything that requires management or further diagnostic workup.Physicians often get caught up in defining Problems and Problem Lists, accusing each other oflumping, splitting, etc. This is unnecessary. Important facts to be noted in constructing aproblem list are these: A. A problem should be defined at its highest level of defensibility. Consider, for example, a beginning medicine clerk who admits a patient with vomiting and confusion. On physical exam the patient is found to have muscle twitching and a pericardial friction rub. The initial lab data reveals a BUN of 100 and potassium of 7.0. The student lists each of these abnormalities as a separate problem. This listing of six problems tells us that the beginning student does not recognize that all of these are manifestations of one problem, uremia. A second-year resident might have recorded the Problem List as having only one problem, uremia, and included all the other abnormalities under that problem. Both Problem Lists are acceptable. The second-year resident is merely reflecting a higher degree of understanding. The following day the clerks Problem List could be modified to facilitate more precise (and less lengthy) daily progress notes. Date Problem Prob.# Problem List Entered Resolved 1 5/2/84 BUN 5/3 uremia 2 5/2/84 K 5/3 See #1 3 5/2/84 Muscle twitching 5/3 See #1 4 5/2/84 Pericardial friction rub 5/3 See #1 5 5/2/84 Vomiting 5/3 See #1 6 5/2/84 Confusion 5/3 See #1Resolving problem 2-6 under 1, uremia, allows one daily progress note to be written for thatproblem and tells an observer reading the patients chart that all the signs and symptoms inproblems 2-6 are related to manifestations of uremia. The date 5/3 tells the observer to seethe notes of that day to explain the redefining of the Problem List. B. The Problem List must include all abnormalities noted in the initial data base. Again, each abnormality need not be separately recorded (see above example). C. The Problem List is refined as problems are either resolved or further defined. 1. Example--Problem Resolved: A patient is admitted with a fever and cough productive of yellow sputum which on Gram stain reveals Gram positive intracellular diplococci. The patient is treated for seven days with penicillin and the patients problem clinically and radiologically resolves. IVMS-ICM/MIC/10/11 Problem Orientated Medical Record (POMR)
  3. 3. Date Problem Prob.# Problem List Entered Resolved pneumococcal pneumonia 1 5/2 5/9The date 5/9 refers an observer to that dates progress note which will explain why theproblem is considered resolved. 2. Problem Further Defined: Consider the first example of the patient with uremia. On day 5/7 a renal biopsy is done which reveals the etiology of the renal failure. The Problem List would then show: Date Problem Prob.# Problem List Entered Resolved BUN 5/3 Uremia 5/7 Secondary 1 5/2 to membranous glomerulonephropathyAgain the date of 5/7 will refer the reader to the progress note for that day which shouldreveal the result of the renal biopsy. D. If the initial data base is incomplete, the Problem List must state so.Example: A female patient who is admitted with upper GI bleeding has not had a pelvic examin 2 years. A pelvic and Pap Smear are not done on admission because the patient isunstable. The problem list must include a problem that states Date Prob.# Problem List Problem Resolved Entered Incomplete Data Base 2 5/2 Pelvic/Pap Not DoneOnce the patient is stable and the pelvic exam/Pap smear is done, the problem is resolved. Date Problem Prob.# Problem List Entered Resolved Incomplete Data Base Pelvic/Paps 2 5/2 5/9 Done-Normal Pelvic/Paps Not Done IVMS-ICM/MIC/10/11 Problem Orientated Medical Record (POMR)
  4. 4. E. The Positive Review of Systems: Many physicians wonder what to do with the patient who answers affirmatively for every question asked in the review of systems. Does each positive have to be recorded separately? Obviously not!Example: For an elderly, lonely female who is admitted with a hip fracture and whosephysical exam is normal except for the hip and whose answers are positive for every questionasked in the review of systems, the physician could list the problems: #1 - Fracture left hip,and #2 - Positive review of systems. Or, recognizing that all these affirmatives may bemanifestations of depression, the physician could list #2 - Depression.INITIAL PLANSThe next process that a physician undertakes after deciding "what is wrong" is "what to doabout what is wrong." This is the initial plan and must be written by the admitting physicianafter the Problem List is constructed.For each problem defined, a SOAP note must be recorded.The Subjective and the Objective are each a brief review of the abnormalities identified in thehistory, physical, and initial lab data, which pertain to that particular problem. These need notbe lengthy, but simply one or two lines reviewing the pertinent data.The Assessment is a brief but pertinent paragraph describing what the physician thinks aboutthat particular problem. If the problem recorded is a sign or symptom requiring a differentialdiagnosis, the DDx must be recorded in a prioritized manner with a brief statement as to whythe physician includes the differential that he or she does. If the problem is a knowndiagnosis (example - asthma), the physician must include in the Assessment a statement thatdescribes the severity and why the problem has worsened requiring admission to thehospital.The Plan must include three distinct groupings: i. Diagnostic Plan: The diagnostic plan includes all the diagnostic workup which the admitting physician feels will be necessary. If the Assessment includes the differential diagnosis, then each must be ruled in or ruled out in the diagnostic plan. This may be done by way of a Venn diagram. Consider a 23 year-old female admitted with pleuritic chest pain for which the admitting physician includes pulmonary embolus, pericarditis, or viral pleuritis in the differential diagnosis. The diagnostic plan may be as follows: IVMS-ICM/MIC/10/11 Problem Orientated Medical Record (POMR)
  5. 5. If the problem is a known diagnosis, then the diagnostic plan must include additional workupneeded either to further define the problem or to assess the severity of the problem. ii. Therapeutic Plan: Must detail all initial therapies started and their rational. iii. Patient Education Plan: Details the initiation of plans to educate the patient of what the problem is and how the patient will deal with it in the future.DAILY PROGRESS NOTESMany physicians object to the POMR because its use results in lengthy, redundant progressnotes. However, when used properly, the POMR does just the opposite and results in notesthat are clear, direct, brief and complete. A few helpful hints regarding the progress notesare: A. A note for each active problem identified need not be written every day. If nothing has changed regarding a particular problem, a note for that problem need not be written. An observer will refer back to the prior day=s note to get a progress report on that particular problem. B. The S, O, A, or P need not be rewritten if nothing is changed for that particular aspect of the problem. C. A common error in writing daily progress notes concerns restating the problem under the Assessment in the daily note. Example: If the problem is congestive heart failure, the Assessment for that particular problem on any day cannot be "congestive heart failure." This is simply a restatement of the problem. However, the physician must give a status report (example - better, worse, or etiology determined) under the assessment.FINAL PROGRESS NOTE OR DISCHARGE SUMMARYThe final progress note should include all active problems, each defined as to its furthestresolution on the Problem List. The Subjective should include a brief review of the course ofsymptoms. The Objective should review the course of objective parameters. TheAssessment and Plan should include the probable course to follow and define end-points as aguide for further therapy. The emphasis on the final progress note should be the unresolvedproblems. Problems which are resolved can be written up briefly. IVMS-ICM/MIC/10/11 Problem Orientated Medical Record (POMR)
  6. 6. REFERENCESBlount, M., Green, S.S., Hamory, A., Kinney, A.B. and Sanborn, C.W., 1978.American Journal of Nursing; 78(9): 1539-42. Documenting with theproblem-oriented record system.Brown, S.H., Miller, R.A., Camp, H.N., Guise, D.A. and Walker, H.K., 1999.Annals of Internal Medicine; 131(2): 117-26. Empirical derivation of anelectronic clinically useful problem statement system.Campbell, J.R., 1998. Proceedings / AMIA Annual Fall Symposium; 285-9.Strategies for problem list implementation in a complex clinical enterprise.Chute, C.G. and Elkin, P.L., 1997. Proceedings / AMIA Annual FallSymposium; 570-4. A clinically-derived terminology: qualification toreduction.Dunea, G. 1978. BMJ; 1(16128): 1686-7. Confusion orientated medicalrecords.Elson, R.B. and Connelly, D.P., 1997. Proceedings / AMIA Annual FallSymposium; 233-7. The impact if anticipatory patient data displays onphysician decision making: a pilot study.Hales, J.W., Schoeffler, K.M. and Kessler, D.P., 1998. Proceedings / AMIAAnnual Fall Symposium; 275-9. Extracting medical knowledge for a codedproblem list vocabulary from the UMLS Knowledge sources.Hayes, G., 1993. Proceedings of the 19th Annual Symposium on ComputerApplications in Medical Care; 103-106. Computers in the Consultation: theUK Experience.Hayes, G., 1996. Proceedings / AMIA Annual Fall Symposium; 454-8. Medicalrecords: past, present and future.Hofing, A.L., McGuigan, M.B. and Merkel, S.I., 1979. Journal of NursingAdministration; 9(12): 43-8. The importance of maintenance in implementingchange: an experience with problem-oriented recording.London, R., Calorosa, E. and Barresi, B.J., 1981. American Journal ofoptometry and Physiological Optics; 58(5): 393-9. Problem orientation invision therapy.Milhous R.L., Aronson M.D., Tormey, D.M. and Ostrowski, C.P., 1978. Journalof Medical Education; 53(2): 137-8. Student and house officer evaluation:the POMR approach compared with other methods.Ludwig, C.A., 1997. Schweizerische Rundschau fur Medizin Praxis; 86(3): 55-8. Problem list in computer-based patient records.Meyers, K.C., Miller, H.J. and Naeymi-Rad, F., 1998. Proceedings / AMIAAnnual Fall Symposium; 325-9. Problem focused knowledge navigation:implementing the problem focused medical record and the O-HEAP note.O’Neil, M.J., Payne, C. and Read, J.D., 1995. Meth Inform Med; 34: 187-92.Read Codes Version 3: A user led Terminology.Salmon, P., Rappaport, A., Bainbridge, M., Hayes, G. and Williams, J., 1996.Proceedings / AMIA Annual Fall Symposium; 463-7. Taking the problem-oriented medical record forward.Scales, J.E. and Johnson, M.S., 1975. Hospital and Community Psychiatry;26(6): 371-3. A psychiatric POMR for use by a multidisciplinary team.IVMS-ICM/MIC/10/11 Problem Orientated Medical Record (POMR)
  7. 7. Shaughnessy, M.K. and Burnett, C.N., 1979. Physical Therapy; 59(2): 160-6.Implementation of the problem-oriented progress note in a skilled nursingfacility.Starfield, B., Steinwachs, D., Morris, I., Siebert, S. and Westin, C., 1979.Medical Care; 17(7): 758-66. Concordance between medical records andobservations regarding information on co-ordination of care.Stratmann W.C., 1980. Medical Care; 18(4): 456-64. Assessing the problem-oriented approach to care delivery.Switz, D.M., 1976. Archives of Internal medicine; 136(10): 1119-1123. Theproblem-oriented medical record: evaluation and management of anaemiabefore and during use.Tait, I.G., 1977. BMJ; 2(6088): 683-8. The clinical record in British generalpractice.Tange, H.J., Schouten, H.C., Kester, A.D. and Hasman, A., 1998. JAMIA;5(6): 571-82. The granularity of medical narratives and its effect on thespeed and completeness of information retrieval.Warren, J.J., Collins, J., Sorrentino, C. and Campbell, J.R., 1998. Proceedings/ AMIA Annual Fall Symposium; 280-4. Just-in-time coding of the problemlist in a clinical environment.Weed, L. L., 1968. NEJM; 278: 593-599. Medical records that guide andteach.Weed, L.L., 1969. Medical Records, Medical Education and Patient Care. TheProblem-Oriented Record as a Basic Tool. Cleveland, Case Western ReserveUniversity Press.IVMS-ICM/MIC/10/11 Problem Orientated Medical Record (POMR)