PROBLEM ORIENTED MEDICAL RECORDING
(POMR)
By:- firoz qureshiDept. psychiatric nursing
DEFINITIONPROBLEM ORIENTED MEDICAL RECORDING (POMR) IS A METHOD OF
PATIENT CARE RECORD KEEPING THAT FOCUSES O SPECIFIC HEALTH
CARE PROBLEMS AND A COOPERATIVE HEALTH CARE PLAN DESIGNED
TO COPE WITH THE IDENTIFIED PROBLEMS(Dorland's Medical
Dictionary for Health Consumers, 2007).
A SYSTEM OF RECORDING KEEPING IN WHICH A LIST OF THE PATIENTS
PROBLEMS IS CREATED AND RELEVANT MEDICAL HISTORY, PHYISCAL
FINDINGS, LABORATORY DATA, MEDICATIOONS AND TREATMENTS ARE
LISTED UNDER THE APPROPRIATE MEEDICAL PROBLEM .(The American
Heritage® Medical Dictionary, 2007)
COMPONENTS1. DATA BASE.
2. PROBLEM LIST.
3. INITIAL PLAN/ NURSING CARE PLAN.
4. PROGRESS NOTES.
5. DISCHARGE SUMMARY.
COMPONENTS1. DATA BASE.2. PROBLEM LIST.3. INITIAL PLAN/NURSING CARE PLAN.4. PROGRESS NOTES. SOAP FORMAT
SUBJECTIVE DATA (S) OBJECTIVE DATA (O) ASSESSMENT (A) PLAN (P)
continuous….
COMPONENTSSOAPIE FORMAT
INTERVENTION (I) EVALUATION (E)
SOAPIER FORMAT REVISION (R)
5. DISCHARGE SUMMARY.
ADVANTAGES OF POMR
CONSISTANCY TO DOCUMENTATION.ORGANIZES INFORMATION. UNIFYING CARE PLAN AND PROGRESS NOTES.ELIMINATES DOCUMENTATION OF NON ESSENTIAL
DATA.SERVES AS A CHECK LIST.EFFECTIVE IN ACUTE AND LONG TERM CARE.MAKES IT EASIER TO TRACK PARTICULAR
PROBLEMS FOR QUALITY ASSURANCE.
DISADVANTAGES OF POMR
EMPHASIS ON CHRONOLOGY OF PROBLEM RATHER THAN PRIORITY.
ANALYZING TRENDS WILL BE DIFFICULT. PRODUCES REPETITIOUS CHARTING. TIME CONSUMING ROUTINE CARE MAY REMAIN UNDOCUMENTED FAILURE OF TEAM MATES TO UPDATE PROBLEM
LIST. TIME AND COST OF TRAINING IS VERY HIGH.
CONTD…… NOT POSSIBLE IN RAPID PATIENT TURN OVER
AREAS.
TRANSITION TO POMR REQUIRES NEW CHARTING TECHNIQUE AND CHANNGE IN THIKING.
RESISTANCE FROM OTHER HEALTH CARE PROFESSIONALS.
COMPARISON BETWEEN NARRATIVE CHARTING AND POMR
HOW TO SWITCH TO POMR
ELECTRONIC APPLICATION OF POMR
RELATION WITH CODING SCHEMES/ TERMINOLOGY
POLICIES AFFECTING
DOCUMENTATION
LEGAL RELEVANCE OF MEDICAL RECORDS
FEASIBILITY OF POMR
ORGANIZATION OF POMR
RESEARCH ABSTRACTS
CONCLUSION
DISCUSSION
COMPARING CHARTING SYSTEMS
SYSTEM
USEFUL SETTINGS
PARTS OF RECORD
ASSESSMENT
CARE PLAN
OUTCOMES AND EVALUATION
PROGRESS NOTES FROMAT
Narrative
Acute care, long term care Home care Ambulatory care
Progress notes Flow sheets to Supplement care plan
Initial: history and Admission form On-going: progress notes
Care plan Progress notes Discharge summary
Narration at time of entry
POMR
Acute care, long term care Home care, rehabilitation Mental health facilities
Data base, care plan Problem list, progress notes, discharge summary
Initial: data base and
Care plan On-going: progress
notes
Data base Nursing care plan based on problem list
Progress notes
SOAP, SOAPIER, SOAPIE
PIE
Acute care
Assessment flow Sheet, progress notes, problem lists
Initial: assessment form On-going: assessment form every shift
None: included in progress Notes (section- P)
Progress notes (section-E)
Problem, Intervention Evaluation
FOCUS
Acute care Long term care
Progress notes Flow sheets Check lists
Initial: patient history and admission assessment On-going: assessment form
Nursing care plan based on problems or nursing diagnosis
Progress notes (section- R)
Data Action Response
CBE
Acute care Long term care
Care plan Flow sheets including patient teachings records and patient discharge notes Graphic record Progress note
Initial: data base assessment Sheet
On-going: nursing and medical order flow sheets
Nursing care plan based on nursing diagnosis
Progress notes (section-E)
SOAPIE or SOAPIER
FACT
Acute care Long term care
Assessment sheet, Flow sheets, Progress notes
Initial: baseline assessment On-going: flow sheets and Progress notes
Nursing care plan based on nursing diagnosis
Flow sheet (section-R)
Data Action Response
AIR
Acute care Long term care
Flow sheets Care plan Progress notes
Initial: baseline assessment On-going : flow sheet and Progress notes
Nursing care plan
Progress notes (section-R)
Assessment Intervention Response
Core
(with DAE)
Acute care Long term care
Kardex Flow sheets Progress notes
Initial: baseline assessment On-going : progress notes
Care plan
Progress notes (section-E)
Data Action Evaluation
THANK YOU
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