Get the free PROBLEM ORIENTED MEDICAL RECORD (POMR)

Clinical Skills ! ! ! ! ! ! ! ! Facility for relating to people (interpersonal skills) Ability to take a history and perform a physical examination Knowing how to evaluate and process incoming information

How to fill out problem oriented medical record

How to fill out a problem-oriented medical record:

1. Begin by gathering all relevant medical information about the patient, including their medical history, current medications, and any previous treatments or surgeries they have undergone.
2. Start by identifying the patient's chief complaint or reason for seeking medical attention. This should be stated clearly and concisely.
3. Next, perform a comprehensive physical examination of the patient. Document any notable findings, such as abnormal vital signs, palpable masses, or significant physical symptoms.
4. Once the physical examination is complete, compile the patient's medical history, including any past illnesses, surgeries, allergies, or chronic conditions. Make sure to note any medications the patient is currently taking and any known drug allergies.
5. Develop an assessment and plan for each identified problem or complaint. This may involve ordering additional diagnostic tests, prescribing medications, referring the patient to a specialist, or recommending lifestyle modifications.
6. Document any diagnostic test results and their interpretations, as well as any consultations with specialists or other healthcare professionals.
7. Follow up with the patient's progress and adjust the treatment plan as necessary. Document any changes or modifications made to the initial assessment and plan.
8. Ensure that all entries in the medical record are dated and signed, with the healthcare provider's name clearly indicated.

Who needs a problem-oriented medical record?

1. Both primary care physicians and specialists can benefit from using a problem-oriented medical record. It allows for a focused and comprehensive approach to patient care, addressing each problem or complaint individually.
2. Hospitals and healthcare facilities also utilize problem-oriented medical records as a standardized method of documenting patient care. This helps promote continuity of care and facilitates effective communication between healthcare providers.
3. Patients may also benefit from problem-oriented medical records, as it helps to ensure that all of their healthcare concerns are properly addressed and documented. This can lead to better coordination of care and improved patient outcomes.

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What is problem oriented medical record?

Problem oriented medical record is a type of medical documentation that focuses on the patient's specific health issues or problems.

Who is required to file problem oriented medical record?

Medical professionals such as doctors, nurses, and other healthcare providers are required to file problem oriented medical records for their patients.

How to fill out problem oriented medical record?

Problem oriented medical records are typically filled out by documenting the patient's current health issues, creating a plan of care, and monitoring the progress of treatment.

What is the purpose of problem oriented medical record?

The purpose of problem oriented medical record is to provide a comprehensive and organized documentation of the patient's health issues, treatment plans, and outcomes.

What information must be reported on problem oriented medical record?

Information such as the patient's medical history, current symptoms, diagnosis, treatment plan, progress notes, and follow-up care should be reported on problem oriented medical record.