KAAU ©2007

Contents:

•Objectives.•The Importance of medical records.•Organizing medical records.•What is POMR and what are its main elements.•How to form a problem list.•Components of a medical record database.•The Initial plan.•How to write a progress note.•Applying the S O A P form.•Summary.

Objectives:

•Understanding the importance of organizing medical records.

•Understanding the main concept of POMR.

•Knowing how to form a problem list.

•Writing medical notes in the form of S O A P.

The Importance of medical records

•Permits easy communication between health professionals for optimum patient care.

•Transferring relevant facts regarding patient care to all health personnel involved.

•Allows ongoing patient health care over a long period of time.

•Permits a quick review of a patient’s total health status.

• Important for proper assessment of the present health problem.

•The management of chronic illnesses requires an accurate dynamic record reflecting past and present medical problems.

•Assisting the physician in predicting the patient’s future health state by identifying risk factors.

Organizing medical records

Includes/

A proper filing system

Organizing each medical record in a systematic way e.g. applying POMR system.

•Filing Systems/

Organizing medical records using an efficient filing system is of great value, especially in terms of quick access and time saving.

•Alphabetical filing system/ Misfiling is common

•Numbering filing system/ Misfiling is Less common

•Color coding/ Misfiling is largely eliminated

Using open shelves is better than closed drawers especially when it is used with the color coding filing system.

Records of patients who have not been seen for 2 or 3 years are considered Inactive.

These files should be isolated to prevent misfiling.

What is POMR and what are its main elements

Is organizing the medical record of each patient in a logical system, beginning with the establishment of a database, after which a problem list is developed, Initial plans are identified, and the patient’s progress is monitored, with continual updating of the database and problem list.

The Four Basic Elements of POMR/

Problem List.

Database.

Initial Plan.

Progress notes.

How to form a problem list

a problem is anything that requires diagnosis or management or that interferes with quality of life as perceived by the patient.

a problem list is a dynamic picture of the patient’s health problem and is changed continually by updating.

The Concept of a Problem List is the single most Important component of POMR.

Problems are either:

1.Active (anything that requires management or further diagnostic workup)

2.Inactive ( problems that are usually prior, resolved medical or surgical illnesses that are still important to be remembered)

Important facts to be noted in constructing a problem list are these:

A problem should be defined at its highest level of defensibility. (depends on degree of understanding)

A. list all findings (physical or lab data) as separate problems, or

B. list problems according to associability

in the second case, the Problem List could be modified to facilitate more precise (and less lengthy) daily progress notes

The Problem List must include all abnormalities noted in the initial data base.

The Problem List is refined as problems are either resolved or further defined

If the initial data base is incomplete, the Problem List must state so.

The Positive Review of System

Ideally, the most diagnostically useful, or "HIGH YIELD" problems are listed first

The MPL should be updated as the case proceeds

The database is composed of/

Complete history.

Physical examination.

Physiologic data.

Baseline laboratory studies.

Components of a medical record database

•The database is the first step toward developing the problem list.

•The database serves as the groundwork for each patient’s future care.

•A complete database is so essential to the success of the POMR that many physicians place “Incomplete database” as problem number 1 in the problem list.

The Initial plan

•The plan must include 3 distinct groupings :

1. Diagnostic plan.

2. Therapeutic plan.

3. Patient education plan.

•Sometimes the initial plan is incorporated with the progress note.

How to write a progress note

•Well organized and logically structured progress notes in addition to the problem list are the secret of POMR effectiveness in promoting continuing patient care.

•Daily progress notes should summarize developments in all the following/

Patient's hospital course.Problems that remains active.Plans to treat those problems.Progress notes should address each element of the problem list.

We use the form S O A P for writing progress notes

S: Subjective

O: Objective

A: Assessment

P: Plan

S = Subjective /

•What the patient states.•Includes any problem or symptom.•e.g. nausea, vomiting, chest pain, appetite, pain, and other symptoms.

O = Objective /

•Always begin with the vital signs.•State your finding in the physical examination•Include new available lab results.

Assessment Plan

Diagnosis ( If known )

Present status of the problem

A diagnosis to rule out

Management /o Medicationo Procedureo Non pharmacological

management

New investigations required

Health education

Assure 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 a separate Assessment and plan for each problem.

Applying the S O A P form

Example of a S O A P progress note /Date Time HD (Hosp. Day) #2 or POD (post-op day) # 2 post appendectomy

S: Pt c/o three episodes of chest pain associated with nausea and vomiting.

O: VS: BP P RR Temp. O2 sat

Chest: clear to auscultation bilaterally CVS : regular rate and rhythm S1 + S2 + 0 Abd : positive bowel sounds, non-tender, non-distended, no hepatosplenomegaly) A/P: 1. HTN: well controlled (or not) on capoten 25 mg Day 2 2. Pneumonia: Improving on Zithromax Day 2/5 (This is Day 2 of a 5 day course)

SIGN YOUR NAME

S O A P can also be used in the following/

Writing short case reports.

Writing patient’s discharge plan.

Presenting cases in rounds

Summary

•Medical record should be well organized to Permits easy communication between health professionals for optimum ongoing patient’s health care.

•POMR is a perfect system for organizing medical records.

•All elements of POMR should be completed including:The problem list, Database, Initial plan and progress notes.

•Well organized progress notes and problem list are the secret of an effective POMR system.

•You must have a complete and accurate problem list for each patient.

•Complete the patient’s record database with proper history, Physical examination and lab results.

•Summarize the patient’s daily health status development in a proper S O A P progress note.

•Always update the record’s database and problem list according to the progress notes.

Thank YouDone by:

Zahir T Fadel

KAAU ©2007