31013_Problem Oriented Medical Records

8/10/2019 31013_Problem Oriented Medical Records

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KAAU 2007


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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.


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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 #.


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#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


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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


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Organizing medical records

Includes/

A proper lin s)stem

Orani!in each medical record in

s)stematic &a) e.g. appl)in POMs)stem.


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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


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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.


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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.


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The !our *asic +lements ofPOM/

Problem ,ist.

-atabase.

Initial Plan.

Progress notes.


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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.


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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#&


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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


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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.


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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


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The database is composed of:

(omplete histor).

#h)sical e;amination.

#h)sioloic data.


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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


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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.


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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.


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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


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$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


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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


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$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.


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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.


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31013_Problem Oriented Medical Records

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