INTRODUCTION

PROBLEM ORIENTED MEDICAL RECORDINGBY:- 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)

COMPONENTSDATA BASE.

PROBLEM LIST.

INITIAL PLAN/ NURSING CARE PLAN.

PROGRESS NOTES.

DISCHARGE SUMMARY.

COMPONENTSDATA BASE.PROBLEM LIST.INITIAL PLAN/NURSING CARE PLAN.PROGRESS NOTES.SOAP FORMATSUBJECTIVE DATA (S)OBJECTIVE DATA (O)ASSESSMENT (A)PLAN (P)

COMPONENTS4. PROGRESS NOTES ( continued)SOAPIE FORMAT INTERVENTION (I)EVALUATION (E)SOAPIER FORMAT REVISION (R) 5. DISCHARGE SUMMARY.

ADVANTAGES OF POMRCONSISTANCY 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 POMREMPHASIS ON CHRONOLOGY OF PROBLEM RATHER THAN PRIORITY.ANALYZING TRENDS WILL BE DIFFICULT.PRODUCES REPETITIOUS CHARTING.TIME CONSUMINGROUTINE CARE MAY REMAIN UNDOCUMENTEDFAILURE OF TEAM MATES TO UPDATE PROBLEM LIST.TIME AND COST OF TRAINING IS VERY HIGH.

CONTDNOT 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

COMPARING CHARTING SYSTEMS

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