POMR Flashcards
Origin of POMR
-a method of recording data about health status of patient in problem solving record
-encourages constant assessment and revision of plan buy everyone involved
Primary purpose of POMR
Comprehensive record of patient’s medical care
-natural flow
-organization (system checks and balances to make certain all aspects of patient care are met)
-provide documents of diagnostics, treatments, communications
Secondary purpose of POMR
Legal record
-majority of time=provincial or local licensing and disciplinary body is contacting you regarding complain from public
-minority of time= court proceedings/lawyers (abuse, disputes)
Keys for medical record
-complete and concise
-legible
-written in blue/black ink or typed
-only pertinent information
-professional language
-clearly ID patient and owner on all forms
-each entry signed and dated
Managing medical records
-They are property of the practice and practice owner BUT owner is entitled to a copy if requested
-Original record must be retained by practice for period specified by licensing body (5 years in SVMA)
-all copies are privileged and confidential
4 components of POVMR
- Data base collection
(history and exam) - Problem ID
(integrate history and exam; give DDx for each problem) - Plan formulation (diagnostic, treatment, client education plan)
- MR documentation assessment and follow up
Initial database components
-signalment (species, age, sex, breed)
-presenting complaint (in owners words)
-medical history (referral info and previous tests)
-physical exam findings
-results of any special exams (ortho, neuro, opthalmic, nutritional)
What is a problem?
Any abnormality ID’d from initial data base that has required, does require, or may require health care
How to make a problem list?
List them in order of importance and diagnostic value
1. help localize disease
eg. being icterus
2. Require specific therapy
3. problem alters prognosis
Differential diagnosis list
Prioritize differentials with most likely first
When to split problems?
-different systems
-different time of onset and clinical course
-uncertain or not known to be secondary to the primary problem
When to lump problems?
-same system
-same time of onset and clinical course
-apparently secondary to the primary problem
Types of plans
- diagnostic plans
- Therapeutic plans
- Client education plans
Diagnostic plans
Includes list of diagnostic tests to help rule out the differentials that you have identified on problem list
ex. whether to perform blood work or diagnostic imaging
ex. monitor plans for certain patient parameters
ex. plan to recheck and monitor physical exams
Treatment plan types
- Specific treatments
- Supportive treatments
- Symptomatic treatment
- Palliative treatment
Specific treatments
-eliminates or modifies the primary cause of the disease processS
Supportive treatments
corrects or modifies abnormalities that occur secondary to the primary disease process
Symptomatic treatment
eliminates or suppresses clinical signs without affecting or knowing the underlying cause
Palliative treatment
Treatment prescribed for an untreatable disease in order to make the patient more comfortable
What needs to be included in a treatment plan?
-written accurately and specifically as possible
-specific drug names
-specific dose, route of administration, frequency of administration and timing
-account for patients dietary and fluid needs in therapeutic plan
**nutritional requirements from formula calculation
Client communication plans
-includes plans to update client by phone, email, text, writing
-discharge notes
-all client communication must be documented
What should be included when speaking with client?
-update on animals status
-update on complications that have occurred
-prognosis update
-financial update
Initial Assessment
-summary of initial data base
-problem list, and DDx, plans showing what diagnostic tests and treatments given, initial communication
-diagnostic test findings
-refined problem list
Ongoing assessments
-occurs after the initial assessment
-documented by SOAP
What is SOAP?
Subjective
Objective
Assessment
Plan
SOAPs
-written for each major problem
-numbered and titled to correspond to the master problem list
-typically written once a day
*critical patients may need multiple times per day
Subjective data
-new or pertinent history
-information obtained from client about medications administered, potential toxin exposure etc
-all non quantitative observations (mental attitude, appetite, water consumption, urination, defecation, activity)
Objective data
Involves anything you can put a number on… all quantitative observations (TPR, physical exam, lab data, radiographic findings etc.)
-abnormal lab values should be mentioned and trends indicated. Only mention normal if it helps rule of DDx
Assessment
Analyzation of new subjective and objective data
**most important part of SOAP
-State diagnosis or rank DDx list
*provide any information that supports or rejects DDx
Plan
-Actions you want to take to manage the problem/disease
-Update any diagnostic or treatment plans (any new tests, adjustments of fluids, medications)
-Communication plan (any change in conditions, plans, complications or give financial update)
Discharge notes
Provide owner with summary of current visit in medical record
-complete discharge notes written in way client can understand
-provide instructions with what is wrong and what owner needs to do at home
-write down when medications are next due
