Principles of Documentation and Charting Flashcards
POMR
Problem-Oriented Medical Record
In chronological order, the components of database:
- General data/demographic data
- c/c
- HPI
- Past medical history
- family history
- personal, social, and environmental history
- review of systems
- physical examination
The ROS can be applied in several ways:
As a head-to-toe screening tool asked of every patient
difference between ROS and physical examination
- ROS contains subjective data pertinent to a specific organ
- PE contains objective data observed by the examiner.
Reports the clinical findings of the therapist based on a thorough examination of the patient
Physical Examination
It is the record of the objective findings, therefore, it must be a list of signs and symptoms
Physical Examination
purpose of physical examination
- to look for evidence that will confirm the subjective complaints
- to look for objective findings that usually accompany the given clinical condition
- together with ROS, it shall be the basis for identifying the problems of pt.
guidelines in performing and recording the Physical Examination
- Keep an honest record
- Constantly repeat the examination procedure
- Always record findings that are both present and absent in the patient
- be brief but use universal language
usually prior, resolved medical or surgical illness and are still important to be remembered
inactive problems
Dr. Weed said that anything that requires management or further diagnostic workup
active problems
it should be defined as its highest level of defensibility
problem
must include all abnormalities noted in the initial database
problem list
is refined as problems are either resolved or further defined
problem list
these are each a brief review of the abnormalities identified in the history, physical and initial lab data, which pertains to a particular problem
Subjective and Objective Data
a brief but pertinent paragraph describing what the physician thinks about the particular problem
Assessment
The plan must include three groupings
- Diagnostic Plan
- Therapeutic Plan
- Patient Education Plan
all the diagnostic workup
diagnostic plan
must detail all initial therapies started and their rationale
therapeutic plan
details the initiation of plans to educate the patient of what the problem is and how the patient will deal with it in the future
patient education plan
a note for each active problem identified need not be written every day. if nothing has changed regarding a particular problem, a note for that problem need not be written
daily progress note
it should include all active problems, each defined as to its further resolution on the Problem List
final progress note or discharge summary
should include a brief review of the course of symptoms
subjective data
should review the course of objectives parameters
objective data
should include the probable course to follow and define end-points as guide for further therapy
assessment and plan
Why POMR is not being used by physiotherapist today
- POMR separates/fragment pts according to their problems
- time consuming for pts with multiple problems
major advantage of POMR
- provide organization and structure to the medical information
- includes a comprehensive list of pt. problems
- discuss each of pts problems and care provided separately
- provides specific plan for managing each of the pt’s problems
- allows a clinician to go directly to that aspect of the note
- provides a chronological sequence of interventions for a particular problem
