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KAAU 2007

Contents:

Objectives.
The Importance of medical records.
Organizing medical records.
What is POMR and what are its main
elements.
How to form a problem list.
Components of a medical record
database.
The Initial plan.
How to write a progress note.
Applying the S O A P form.

Objectives:
Understanding the importance of organizing
medical
records.
Understanding the main concept of POMR.
Knowing how to form a problem list.
Writing medical notes in the form of S O A P.

Permits easy communication


between health
professionals for optimum patient
care.
Transferring relevant facts regarding
patient
care to all health personnel
involved.
Allows ongoing patient health

Important for proper assessment


of the
present health problem.
The management of chronic
illnesses
requires an accurate dynamic
record
reflecting past and present
medical
problems.
Assisting the physician in

Organizing medical records


Includes/
A proper filing system

Organizing each medical record in a


systematic way e.g. applying POMR
system.

Organizing medical records using an efficient


filing system is of great value, especially in terms
of quick access and time saving.
Alphabetical filing system/
common

Misfiling is

Numbering filing system/


common

Misfiling is Less

Color coding/
largely eliminated

Misfiling is

Using open shelves is better than closed


drawers especially when it is used with
the color coding filing system.
Records of patients who have not been
seen for 2 or 3 years are considered
Inactive.
These files should be isolated to prevent
misfiling.

elements
Is organizing the medical record of each
patient in a logical
system, beginning with the establishment of
a database,
after which a problem list is developed,
Initial plans are
identified, and the patients progress is
monitored, with
continual updating of the database
and problem list.

The Four Basic Elements of


POMR/
Problem List.
Database.
Initial Plan.
Progress notes.

How to form a problem list

a problem is anything that requires diagnosis or


management or that interferes with quality of life
as perceived by the patient.
a problem list is a dynamic picture of the
patients health problem and is changed
continually by updating.

The Concept of a Problem List is the single most


Important component of POMR.
Problems are either:
1.Active (anything that requires management or further
diagnostic workup)
2.Inactive ( problems that are usually prior, resolved
medical or surgical illnesses that are still important to be
remembered)

Important facts to be noted in constructing a problem list


are these:
A problem should be defined at its highest level of
defensibility. (depends on degree of understanding)
A. list all findings (physical or lab data) as separate
problems, or
B. list problems according to associability
in the second case, the Problem List could be modified to facilitate
more precise (and less lengthy) daily progress notes

The Problem List must include all


abnormalities noted in the initial data base.
The Problem List is refined as problems are
either resolved or further defined
If the initial data base is incomplete, the
Problem List must state so.

The Positive Review of System


Ideally, the most diagnostically useful, or
"HIGH YIELD" problems are listed first
The MPL should be updated as the case
proceeds

Components of a medical record


database

The database is composed of/

Complete history.
Physical examination.
Physiologic data.
Baseline laboratory studies

The database is the first step toward


developing the problem list.
The database serves as the groundwork
for each patients future care.
A complete database is so essential to the
success of the POMR that many physicians
place Incomplete database as problem
number 1 in the problem list.

The Initial plan


The plan must include 3 distinct groupings :
1. Diagnostic plan.
2. Therapeutic plan.
3. Patient education plan.
Sometimes the initial plan is incorporated with the progress note .

How to write a progress note


Well organized and logically structured
progress notes in addition to the problem list
are the secret of POMR effectiveness in
promoting continuing patient care.
Daily progress notes should summarize
developments in all the following/
Patient's hospital course.
Problems that remains active.
Plans to treat those problems.
Progress notes should address each
element of the problem list.

We use the form S O A P for writing


progress notes
S: Subjective
O: Objective
A: Assessment
P: Plan

S = Subjective /
What the patient states.
Includes any problem or symptom.
e.g. nausea, vomiting, chest pain, appetite,
pain, and other symptoms.
O = Objective /
Always begin with the vital signs.
State your finding in the physical examination
Include new available lab results.

A & P = Assessment and Plan /


It is better to present them together in a list with a
separate Assessment and plan for each problem.
Assessment

Diagnosis ( If known )

Present status of the


problem

A diagnosis to rule out

Plan
Management /
o Medication
o Procedure
o Non pharmacological
management

New investigations required

Health education

Assure continuing the


previous plan ( If no new
plan is needed )

Applying the S O A P form


Example of a S O A P progress note /

Date
Time
HD (Hosp. Day) #2 or POD (post-op day) # 2 post appendectomy
S: Pt c/o three episodes of chest pain associated
with nausea and vomiting.
O: VS: BP P RR Temp. O2 sat
Chest: clear to auscultation bilaterally
CVS : regular rate and rhythm S1 + S2 + 0
Abd : positive bowel sounds, non-tender, non-distended, no
hepatosplenomegaly)

A/P:
1. HTN: well controlled (or not) on capoten 25 mg Day 2
2. Pneumonia: Improving on Zithromax Day 2/5
(This is Day 2 of a 5 day course)
SIGN YOUR NAME

S O A P can also be used in the following/


Writing short case reports.

Writing patients discharge plan.

Presenting cases in rounds

Summary

Medical record should be well organized to Permits easy


communication between health professionals for optimum
ongoing patients health care.
POMR is a perfect system for organizing medical
records.
All elements of POMR should be completed including:
The problem list, Database, Initial plan and
progress notes.
Well organized progress notes and problem list are
the
secret of an effective POMR system.

You must have a complete and accurate problem


list for each patient.
Complete the patients record database with proper
history, Physical examination and lab results.
Summarize the patients daily health status
development in a proper S O A P progress note.
Always update the records database and problem
list
according to the progress notes.

Thank
You
Done by:
Zahir T Fadel

KAAU 2007

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