problem oriented medical recording (pomr)

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


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


SOAPIE or SOAPIER

FACT


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


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)


Kardex Flow sheets Progress notes

Initial: baseline assessment On-going : progress notes

Care plan


Data Action Evaluation

THANK YOU

problem oriented medical recording (pomr)

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