POMR

Problem-Oriented Medical Record (POMR) is a method of recording data about the health status of a patient in a problem-solving system. It was developed by Dr. Lawrence Weed in the 1960s as a way to organize a patient's medical record. The POMR system is designed to improve the quality of patient care by making the medical record more systematically organized, comprehensive, and accessible to healthcare providers.

Overview

The POMR system organizes the medical record by problems, each of which is numbered and listed at the beginning of the record. Each problem is documented in a structured format that includes four components: database, problem list, initial plans, and progress notes. This structure is known as the SOAP format, which stands for Subjective, Objective, Assessment, and Plan.

Database

The database contains all the information collected about the patient, including medical history, physical examination findings, laboratory results, and other diagnostic data. This comprehensive collection of data serves as the foundation for identifying and understanding the patient's problems.

Problem List

The problem list is a numbered list of all the significant health issues that the patient has, both active and inactive. Each problem is clearly stated and dated, providing a quick overview of the patient's health status at any given time.

Initial Plans

For each problem identified, an initial plan is developed, outlining the diagnostic, therapeutic, and patient education plans. This plan guides the healthcare team in managing the patient's care.

Progress Notes

Progress notes are documented using the SOAP format. These notes detail the ongoing assessment and management of each problem on the list, including changes in the patient's condition, results of tests, responses to treatments, and updates to the plan as needed.

Advantages

The POMR system offers several advantages over traditional medical records. It promotes a more organized and systematic approach to patient care, facilitates communication among healthcare providers, and enhances continuity of care. Additionally, it helps in the educational process of medical students and residents by providing a clear structure for problem-solving and decision-making.

Disadvantages

Despite its benefits, the POMR system has some limitations. It can be time-consuming to maintain, requires thorough training for effective use, and may lead to redundancy in the medical record. Additionally, the system's focus on problems may inadvertently emphasize negative aspects of patient care.

Implementation

The adoption of the POMR system varies across healthcare settings. It has been more widely implemented in electronic health record (EHR) systems, where its structured format can be easily integrated and managed. However, successful implementation requires commitment from the healthcare institution and its providers to adhere to the system's principles and processes.