Post on 02-Jun-2018
8/10/2019 31013_Problem Oriented Medical Records
1/28
KAAU 2007
8/10/2019 31013_Problem Oriented Medical Records
2/28
Contents:
Objectives.The Importance of medical records.Orani!in medical records."hat is #O$% and &hat are its mainelements.'o& to form a problem list.(omponents of a medical record
database.The Initial plan.'o& to &rite a proress note.
Appl)in the * O A # form.
8/10/2019 31013_Problem Oriented Medical Records
3/28
Objectives:
Understandin the importance of orani!inmedical
records.
Understandin the main concept of #O$%.
Kno&in ho& to form a problem list.
"ritin medical notes in the form of * O A #.
8/10/2019 31013_Problem Oriented Medical Records
4/28
#ermits eas) comm+nicationbet&een health
professionals for optim+m patientcare.
Transferrin relevant facts reardinpatient
care to all health personnelinvolved.
Allo&s onoin patient health
8/10/2019 31013_Problem Oriented Medical Records
5/28
Important for proper assessmentof the
present health problem.
The manaement of chronic
illnesses re,+ires an acc+rate d)namicrecord
re/ectin past and present
medicalproblems.
Assistin the ph)sician in
8/10/2019 31013_Problem Oriented Medical Records
6/28
Organizing medical records
Includes/
A proper lin s)stem
Orani!in each medical record in
s)stematic &a) e.g. appl)in POMs)stem.
8/10/2019 31013_Problem Oriented Medical Records
7/28
Orani!in medical records +sin an e1cientlin s)stem is of reat val+e especiall) in term
of ,+ic- access and time savin.
$lphabetical %ling s#stem/ $islin is
common
&umbering %ling s#stem/ $islin is 3esscommon
Color coding/ $islin islarel) eliminated
8/10/2019 31013_Problem Oriented Medical Records
8/28
Usin open shelvesis better than closed
dra&ers especiall) &hen it is +sed &iththe color codin lin s)stem.
%ecords of patients &ho have not beenseen for 2 or 4 )ears are consideredInactive.
These les sho+ld be isolated to preventmislin.
8/10/2019 31013_Problem Oriented Medical Records
9/28
e emen s
Is orani!in the medical record of eachpatient in a loicals)stem beinnin &ith the establishment ofa database
after &hich a problem list is developedInitial plansareidentied and the patient)s progress ismonitored &ith
continual updating of the databaseand problem list.
8/10/2019 31013_Problem Oriented Medical Records
10/28
The !our *asic +lements ofPOM/
Problem ,ist.
-atabase.
Initial Plan.
Progress notes.
8/10/2019 31013_Problem Oriented Medical Records
11/28
o( to form a problem list
a problem is an)thin that re,+ires dianosis ormanaement or that interferes &ith ,+alit) of lifeas perceived b) the patient.
a problem list is a d)namic pict+re of the
patients health problem and is chanedcontin+all) b) +pdatin.
8/10/2019 31013_Problem Oriented Medical Records
12/28
8/10/2019 31013_Problem Oriented Medical Records
13/28
The Concept of a Problem List is the single most
Important component of POMR.
Problems are either:
1.Active(anthing that re!"ires management or f"rther
#iagnostic $or%"p&
'.Inactive( problems that are "s"all prior resolve#
me#ical or s"rgical illnesses that are still important to beremembere#&
8/10/2019 31013_Problem Oriented Medical Records
14/28
Important facts to be note# in constr"cting a problem list
are these:
A problem sho"l# be #efine# at its highest level of
#efensibilit. (#epen#s on #egree of "n#erstan#ing&
A. list all fin#ings (phsical or lab #ata& as separateproblems or
). list problems accor#ing to associabilit
in the secon# case the Problem List co"l# be mo#ifie# to facilitate
more precise (an# less length& #ail progress notes
8/10/2019 31013_Problem Oriented Medical Records
15/28
The #roblem 3ist m+st incl+de allabnormalities noted in the initial data base.
The #roblem 3ist is rened as problems areeither resolved or f+rther dened
If the initial data base is incomplete the#roblem 3ist m+st state so.
8/10/2019 31013_Problem Oriented Medical Records
16/28
The #ositive %evie& of *)stem
Ideall) the most dianosticall) +sef+l or
5'I6' I8395 problems are listed rst
The $#3 sho+ld be +pdated as the caseproceeds
8/10/2019 31013_Problem Oriented Medical Records
17/28
The database is composed of:
(omplete histor).
#h)sical e;amination.
#h)sioloic data.
8/10/2019 31013_Problem Oriented Medical Records
18/28
8/10/2019 31013_Problem Oriented Medical Records
19/28
The Initial plan
*The plan m"st incl"#e + #istinct gro"pings :
1. ,iagnostic plan.
'. Therape"tic plan.
+. Patient e#"cation plan.
*-ometimes the initial plan is incorporate# $ith the progress note.
o( o (r e a progress no e
8/10/2019 31013_Problem Oriented Medical Records
20/28
o( o (r e a progress no e
"ell orani!ed and loicall) str+ct+redprogress notesin addition to the problem listare the secret of POMe@ectiveness inpromotin contin+in patient care.
-ail# progress notes should summarizedevelopments in all the follo(ing/
#atients hospital co+rse.#roblems that remains active.#lans to treat those problems.#roress notes sho+ld address each
element of the problem list.
8/10/2019 31013_Problem Oriented Medical Records
21/28
8/10/2019 31013_Problem Oriented Medical Records
22/28
S = Subjective/
What the patient states.Includes any problem or symptom.e.g. nausea, vomiting, chest pain, appetite, pain, and other symptoms.
O = Objective/
Al&a)s bein &ith the vital sins.*tate )o+r ndin in the ph)sical e;aminationIncl+de ne& available lab res+lts.
8/10/2019 31013_Problem Oriented Medical Records
23/28
Assessment Plan
Diagnosis ( If known
!resent status of the
problem
" diagnosis to rule out
#anagement /
o #edication
o !rocedure
o $on pharmacological
management
$ew investigations re%uired
&ealth education
"ssure continuing the
previous plan ( If no new
plan is needed
A & P = Assessment and Plan/
It is better to present them together in a list with aseparate "ssessment and plan for each problem.
$ l i th " O $ P f
8/10/2019 31013_Problem Oriented Medical Records
24/28
$ppl#ing the " O $ P form
+ample of a " O $ P progress note /Date
'ime &D (&osp. Day ) or !*D (post+op day ) post appendectomy
S: !t c/o three episodes of chest pain associatedwith nausea and vomiting.
O: - ! ! 00 'emp. *)sat
1hest clear to auscultation bilaterally 1- regular rate and rhythm -2 3 -) 3 4 "bd positive bowel sounds, non+tender, non+distended, no hepatosplenomegalyA/P:
2. &'$ well controlled (or not on capoten )5 mg Day ) ). !neumonia Improving on 6ithroma7 Day )/5 ('his is Day ) of a 5 day course
SIGN YOUR NAME
8/10/2019 31013_Problem Oriented Medical Records
25/28
S O A P can als be used in t!e "ll#in$/
Writing short case reports.
Writing patients discharge plan.
!resenting cases in rounds
8/10/2019 31013_Problem Oriented Medical Records
26/28
$edical record sho+ld be &ell orani!ed to #ermits eas)comm+nication bet&een health professionals for optim+onoin patients health care.
POM is a perfect s)stem for orani!in medicalrecords.
All elements of POMsho+ld be completed incl+dinCThe problem list0 -atabase0 Initial plan and
progress notes.
"ell orani!ed progress notesand problem listarethe
secret of an e@ective #O$% s)stem.
8/10/2019 31013_Problem Oriented Medical Records
27/28
o+ m+st have a complete and acc+rate problemlist for each patient.
(omplete the patients record database&ith properhistor#0 Ph#sical eamination and lab results.
*+mmari!e the patients dail) health stat+sdevelopment in a proper " O $ Pprogress note.
Al&a)s update the records databaseand problemlist accordin to the proress notes.
8/10/2019 31013_Problem Oriented Medical Records
28/28