Problem-Oriented Medical Record in Electronic Healthcare System: Guide to Systematic Writing

by Gheun-Ho Kim

Overview

Problem Oriented Medical Record (POMR) has been a standard of physicians’ record since it was introduced in 1968 by Dr. Lawrence Weed. However, many physicians are unaware of its principles and do not apply it in a correct way in clinical practice. This book will describe how to systematically write medical records for the diagnostic and therapeutic approaches. This book will cover principles and practice of POMR for care of inpatients and outpatients. The importance of medical records cannot be overemphasized, but many trainees are not educated for the right way of POMR. Thus, this book will provided the right concept of POMR and correct way of medical writing, compatible with the principles of POMR.

Product Details

ISBN-13:	9789819741885
Publisher:	Springer Nature Singapore
Publication date:	09/14/2024
Edition description:	2024
Pages:	92
Product dimensions:	7.01(w) x 10.00(h) x (d)

About the Author

Gheun-Ho Kim MD, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea

Table of Contents

1. What is the medical record?.- 2. Problem versus Impression.- 3. POMR for inpatients.- 4. Admission note.- 5. Progress note.- 6. Discharge summary.- 7. POMR for outpatients.- 8. POMR in the era of electronic health record.

Editorial Reviews

Reviewer: Stephanie Murray, MD (University of Kansas School of Medicine - Wichita)
Description: This book references the Problem-Oriented Medical Record (POMR), originally introduced by Dr. Lawrence Weed in 1968 as a format for systematic medical writing and explores its implementation in modern electronic health records (EHRs). It defines components of the medical record, instructs on creation of a POMR, and provides inpatient and outpatient POMR examples.
Purpose: The primary aim of this book is to provide a thorough education on the POMR's principles and applications, fostering a consensus on its terminology, and encouraging the development of EHR systems that integrate POMR effectively. It transcends mere documentation efficiency, aiming to enhance clinical decision-making through structured data analysis. The book successfully meets its educational and developmental objectives, pushing for physician involvement in health information systems.
Audience: Targeted at clinicians across all specialties who engage with EHRs, the book serves both novices and veterans. It offers foundational knowledge for newcomers on clinical reasoning and problem list creation, while discussing EHR integration for those interested in health information technology. It is particularly valuable for those keen on understanding or implementing POMR.
Features: The book is structured logically, beginning with the history of medical records and journeying through the science of clinical reasoning into the details of POMR including the database, problem list, plan, and progress notes, relating these to the traditional SOAP note. It also ventures into future possibilities with EHRs and AI, though these are conceptual rather than reflective of current capabilities. The inclusion of visual aids like simplified EHR screenshots helps in visualizing the integration. The book concludes with practical examples of POMR in different clinical settings, showcasing both notes and problem list configurations.
Assessment: This publication stands out as an excellent introduction to POMR, potentially enhancing clinicians' documentation skills. While many practitioners unknowingly use POMR elements, full adoption faces hurdles, including resistance to change and the need for advanced EHR functionalities not yet widely available. The requirement for a dynamic, well-integrated problem list presents a significant challenge, yet the benefits to clinical practice are clear. The book advocates for physicians to influence EHR development for better POMR support, highlighting the potential of these skills to improve clinical practice. Overall, the book is an insightful resource for anyone looking to deepen their understanding or implementation of POMR within contemporary healthcare settings.

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