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.
Misfiling is
Misfiling is Less
Color coding/
largely eliminated
Misfiling is
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.
Complete history.
Physical examination.
Physiologic data.
Baseline laboratory studies
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.
Diagnosis ( If known )
Plan
Management /
o Medication
o Procedure
o Non pharmacological
management
Health education
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)
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Summary
Thank
You
Done by:
Zahir T Fadel
KAAU 2007