The Four Main Components
The problem-oriented record (POR), also known as the problem-oriented medical record (POMR), is structured around four distinct and interdependent components. This design ensures that all documentation is tied to a patient's specific health issues, which contrasts with the less organized, source-oriented model.
1. The Database
The database is the foundational component of the POR, a comprehensive collection of all relevant patient information. It is established upon the patient's first encounter with the healthcare system and includes patient history, physical examination findings, and laboratory and diagnostic results.
2. The Problem List
The problem list chronicles the patient's health issues, active and resolved, derived from the database. Each entry should be numbered, dated, and titled, and can include diagnoses, symptoms, abnormal lab values, or social/functional issues. A well-maintained list includes the problem's number, description, date of identification, status, and resolution date if applicable.
3. The Initial Plan
Developed for each problem, the initial plan outlines the course of action to address each issue. According to Loyola University Chicago, it is divided into a diagnostic plan for further tests, a therapeutic plan for treatments and medications, and a patient education plan.
4. The Progress Notes
Progress notes provide ongoing documentation, with each note corresponding to a specific problem. The common SOAP method structures notes into Subjective (patient reports), Objective (measurable data), Assessment (clinician's analysis), and Plan (next treatment steps).
Comparison: Problem-Oriented vs. Source-Oriented Records
Contrasting the POR with the traditional source-oriented record (SOR) highlights the differences in information organization. The POR organizes data by the patient's problems, allowing quick access to all relevant information for a specific issue. The SOR organizes data by the source, which may require searching multiple sections. The POR is patient-centered and focuses on current issues and plans, while the SOR is more history-focused by source. The POR centralizes interdisciplinary notes, improving communication, while the SOR segregates notes by profession.
| Feature | Problem-Oriented Record (POR) | Source-Oriented Record (SOR) |
|---|---|---|
| Organization | Organized around the patient's specific health problems. | Organized according to the source or type of data (e.g., physician notes, lab reports, nurse's notes). |
| Data Retrieval | Facilitates quick access to all information related to a specific problem. | May require searching through multiple sections to find all information for a single problem. |
| Focus | Patient-centered and focused on current health issues and treatment plans. | More history-focused, offering a broader historical context arranged by source. |
| Interdisciplinary Communication | Centralizes interdisciplinary progress notes, promoting better communication among the care team. | Segregates notes by profession, which can create communication barriers. |
Advantages of the Problem-Oriented Record
The POR's systematic approach offers several advantages. It improves organization and clarity, making it easier to manage complex conditions. Enhanced communication among the healthcare team is facilitated by the centralized, problem-focused structure. It also improves continuity of care as patients move through the system and facilitates auditing and evaluation.
The Role of POR in Modern Electronic Health Records
The principles of the POR are integrated into modern electronic health record (EHR) systems. EHRs based on the POR model use a structured problem list to guide clinical decisions, manage orders, and support population health. This digital implementation enhances functionality with features like automated alerts and improved data analysis.
Conclusion
The problem-oriented record, with its database, problem list, initial plan, and progress notes, provides a systematic and patient-centered approach to medical documentation. Organizing information by health issues improves communication and ensures consistent, holistic care. The POR's structure is valuable for both paper and electronic records, highlighting its importance in quality patient care.
