Understanding the Core Components of a POMR
A problem-oriented medical record (POMR), conceived by Dr. Lawrence Weed, is a structured approach to patient charting that emphasizes organizing medical information around a patient's specific health issues. Unlike traditional source-oriented records, which group information by its origin (e.g., all lab results in one section), the POMR links all clinical activities and findings directly to a numbered problem. This approach enhances communication among healthcare providers and improves the continuity of care by keeping the focus on the patient's individual needs.
There are four distinct components that make up a complete POMR. Each section plays a crucial role in painting a comprehensive picture of the patient's health and guiding the clinical decision-making process.
The Foundational Data Base
The data base is the initial, foundational component of the POMR and includes all the information gathered at the patient's first encounter. It provides the baseline data that the healthcare team will use to identify and manage the patient's problems.
- Chief Complaint (CC): The primary reason for the patient's visit, as described in their own words.
- History of Present Illness (HPI): A detailed account of the patient's current symptoms, including their onset, duration, location, and severity.
- Patient History: A thorough collection of the patient's medical, surgical, family, and social history.
- Physical Examination Findings: The results of a comprehensive physical assessment performed by the clinician.
- Laboratory and Diagnostic Test Results: Any initial lab work, imaging reports (e.g., x-rays, CT scans), and other diagnostic data that provides objective evidence of the patient's condition.
The Complete Problem List
After compiling the data base, a prioritized and categorized list of the patient's problems is created. A problem can be a diagnosis, a symptom, an abnormal lab value, or a social issue that requires management. This list serves as a table of contents for the entire record, and each problem is numbered and titled.
- Chronic Conditions: Long-standing diagnoses such as diabetes, hypertension, or asthma.
- Acute Problems: Temporary issues like an ear infection or a broken bone.
- Inactive/Resolved Problems: Past conditions that are no longer active but are important for context.
- Social or Psychological Problems: Issues that affect a patient's well-being, such as housing instability or anxiety.
The Initial Plan for Each Problem
For each problem identified on the problem list, a specific plan of action is developed. This initial plan outlines the steps the healthcare team will take to address the problem. The plan is organized into three distinct parts:
- Diagnostic Plan: Outlines any necessary tests or procedures to further evaluate the problem or confirm a diagnosis.
- Therapeutic Plan: Details the treatment approach, including medications, therapies, or surgical interventions.
- Patient Education Plan: Describes the process for educating the patient about their condition and their role in managing it.
The Daily Progress Notes (SOAP Format)
Progress notes are the ongoing documentation of a patient's progress and care. They are written for each specific problem using the well-known SOAP (Subjective, Objective, Assessment, Plan) format. This structured approach ensures that every aspect of the patient's care is documented consistently.
- Subjective (S): The patient's reported symptoms, feelings, and concerns.
- Objective (O): The clinician's observations and measurable data, such as vital signs, lab results, and physical exam findings.
- Assessment (A): The clinician's interpretation and synthesis of the subjective and objective data, leading to a diagnosis or an update on the patient's condition.
- Plan (P): The course of action, including treatment modifications, follow-up tests, and patient education.
Comparing POMR with Traditional Records
| Feature | Problem-Oriented Medical Record (POMR) | Traditional Source-Oriented Record | Comparison Insight |
|---|---|---|---|
| Organization | Organized by the patient's specific health problems. | Organized by the source of the information (e.g., nurse's notes, doctor's notes, lab results). | POMR provides a focused, problem-specific view, while traditional records can be fragmented. |
| Continuity of Care | Excellent, as all providers can quickly review the problem list and corresponding notes. | Can be challenging, requiring providers to sift through multiple sections to find relevant information for a single problem. | The POMR's structure makes it ideal for managing complex, chronic conditions. |
| Focus | Patient-centric, with all documentation directly related to identified problems. | Provider-centric, with each professional documenting their own findings independently. | The POMR's focus on problems ensures all care aligns with the patient's most pressing issues. |
| Documentation Format | Primarily uses the SOAP format within progress notes, linking directly to the problem list. | Often uses a less structured, narrative-style format, organized chronologically by visit. | SOAP notes enforce a standardized, easy-to-follow structure for each entry. |
| Updating | The master problem list is updated as problems resolve or new issues arise. | New information is simply added chronologically, with no central list to track problem status. | The dynamic problem list is a key strength of the POMR, ensuring the record remains current and relevant. |
Conclusion: The Holistic View
The problem-oriented medical record is much more than a simple record-keeping tool; it is a philosophy of patient care. By forcing healthcare professionals to synthesize a complete picture from the initial data base and organize their thinking around a specific, ever-evolving problem list, the POMR fosters more thorough and consistent patient management. It ensures that each clinical encounter contributes to a coherent narrative of the patient's health journey, making it easier for any member of the care team to understand the patient's history and ongoing needs. For a deeper dive into its origins, you can explore the historical context of the problem-oriented medical record and its evolution in modern healthcare. Ultimately, a well-maintained POMR leads to improved communication, better decision-making, and more focused, effective care for the patient.
