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Is the Problem-Oriented Medical Records (POMR) Approach Worth the Effort?

If you are a doctor, chances are that you know about POMR. And that means that you are either in one of two camps: You either love POMR or you hate it.

But have you ever stopped and considered why the approach was introduced and its advantages over the other methods? Read this article to find out how POMR can help you give better care to patients, and improve your practice.

Read this article to find out how POMR can help you give better care to patients, and improve your practice.

In this article, we are going to look at the origins of the POMR approach, why some doctors love it while others hate it, its advantages, disadvantages and advise on how to get the most out of it.

So, let’s get started with problem oriented charting.

The Origins of POMR Charting and Why It is So Popular

Problem Oriented Medical Records (POMR) were first described by Dr. Lawrence Weed in 1968. As a patient-focused approach, POMR is advantageous to both patients and providers.

The problem is that many doctors avoid using it, arguing that it’s too cumbersome, has many data synthesis restrictions and requires one to take a lot of notes.

Doctor discussing medical records with patient
Doctor discussing medical records with patient

On the other hand, the professionals who love the POMR method argue that when properly used, POMR goes contrary to its name and produces complete, concise and accurate records, particularly with the management and reporting of chronic health conditions.

But you are probably wondering: Is there an advantage to using POMR?
POMR is the official method of keeping records used by most medical centers around the world as well as most undergraduate medical schools.

POMR stores information in a way that can be easily accessed and promotes
continuous review and revisions of the healthcare plan by every member of the healthcare team. The result is complete, concise and accurate records.

POMR is so important that SOAP notes originate from it.

More on this later.

POMR Charting and The Problem It Solves?

The need for improved management of healthcare conditions is what resulted in POMR. Chronic illnesses require frequent interventions and encounters with the patient, creating the need for tracking care over time.

Besides, each patient requires unique medical solutions.

POMR is part of the attempt to address the most common problems in diagnosis and patient management. The first problem is inadequate hypothesis generation and inattention while the second problem is the misinterpretation of findings.

Problems with Electronic Health Records and Why You Should Consider Adopting POMR

The first objective of problem oriented medical diagnosis is teaching and learning. Its emphasis on a system and analytical approach helps the physician to learn disease patterns.

Reviewing these patterns on a later date helps the physician to determine how best to help the patient.

Here’s how:

POMR helps integrate problems with their causes, forcing the physician to focus on the patient and his/her problems. Through POMR, student doctors’ understanding may be evaluated based on their understanding of clinical blocks.

POMR enhances communication between members of the medical team, which effectively increases the quality of care and reduces the chances of making serious mistakes.

Doctor giving patient a physical exam
Doctor giving patient a physical exam

As a legal record, each physician has to sign their entries, which encourages them to take their jobs more seriously.

That’s not all…

POMR helps healthcare practitioners identify patterns. For example, it helps doctors identify uncommon occurrences of common diseases, the common occurrence of uncommon diseases, and diseases which may be common or not that has not been seen or recognized before.

Components of POMR, their Relationship and How they Enhance Your Practice

POMR is a defined information database.

POMR consists of a complete problem list that can be broken down into:

  • Filtered problems by status: Current (improving or worsening), dormant (no change) or resolved.
  • Grouped in chronological order, based on either the entry or encounter date.
  • The system only allows the physician to consider one problem at a time. It is not uncommon to find that during a single visit the reporting of several problems may be necessary.

POMR involves a plan of action for every listed problem broken down based on: Status, basis, disability, goal, following the course, extra investigation and awareness of likely complications.

What’s the bottom line?

POMR also requires the physician to take notes on the patient’s progress. It involves documenting the patient’s and others’ feedback, follow up and adjustments planned over time.

POMR Components in Detail and the Rationale Behind Them

Component 1: Database

Patient data is collected prior to starting the identification of the patient’s problems and stored in a database.

The collected data must include a complete physical exam and patient history. Some of the common lab tests include SMAC, CBC, x-rays, EKG and urinalysis for every patient admitted into the facility.

If such details can be accessed by the admitting doctor, they must be present in the original database. This should be accompanied by the patient’s history and physical exam.

All the additional information gathered is added to a database.

Component 2: Complete Problem List

After conducting the physical exam, getting the medical history and viewing the patient’s records in the database, the doctor constructs and records the problem list.

When creating the problem list, the doctor identifies what is wrong with the patient.

What do doctors actually record as problems?

Basically, it is anything of concern either to the caregiver, the patient or both. These may be psychological disturbances, physical abnormalities, or socioeconomic problems.

The list of problems is usually arranged in four or five categories: a chronological problem list, dates when the problems started, the taken actions, their results, and what the interventions accomplished.

Look:

It is important that the physician remember that problems may either be active or inactive. The latter refers to previously resolved problems that are significant enough for the doctor to keep in mind.

But here is the problem…

In many cases, physicians get tied up in defining problems and problem lists. They end up accusing one another of splitting or lumping problems. In a POMR, the problem is usually defined at greatest possible defensibility level.

For example:

Let’s say a student doctor admits a patient presenting with confusion and vomiting.

After giving the patient a physical, the student doctor finds that the patient suffers from pericardial friction rub and muscle twitching. Lab results show that the patient’s potassium is at 7.0 and they have a BUN of 100.

Then, the medical student lists all the symptoms as separate problems. This shows that the medical student does not understand that all the six symptoms are indicative of uremia.

However, a more experienced student may identify uremia as the problem and list all the other symptoms beneath it.

So who is right?

In POMR, both students’ records are acceptable. The more experienced student demonstrates a higher degree of understanding while the less experienced one may soon modify their list to make them more precise.

The problem list must contain all the abnormalities recorded to the initial database. The list of problems is then refined as either resolved or further defined.

In case the initial database is incomplete, the problem list must indicate the same.

If the Patient Gives Affirmative Answers to Every Question, What Should You Do?

If the patient answers affirmatively to all the questions asked by the physician during the review of body systems, each affirmative response needn’t have a separate record.

For instance, the physician may record in the patient’s file that they suffer from a “broken femur and positive review of systems.” However, if all the affirmatives are indicative of depression, then the physician will record it as “depression”.

Component 3: Initial Plans

After deciding what is wrong, the next step involves determining what to do to right the wrong. Usually, the initial plan is written by the doctor who admits the patient after coming up with the problem list.

In this case, the doctor has to create a SOAP note for each problem.
The SOAP format consists of:
S (Subjective data acquired from the patient)
O (Objective data after a physical examination, laboratory tests, ECG and radiological tests)
A (Assessment, where the doctor analyzes both subjective and objective data)
P (Plan which may include further diagnoses, therapy education or counselling)

Why Some Physicians Hate POMR and How to Make them Appreciate it More

Many physicians object to the POMR system because it uses long redundant progress notes. When used properly, however, POMR produces notes that are clear, direct, brief and complete.

One thing that can help physicians as they create SOAP notes is that there is no need to have a note for each active problem on a daily basis.

I’m not going to lie to you…

If nothing changes with regards to a particular patient problem, there is no need to record that problem. The physician only needs to reference the previous day’s notes.

Besides, the SOAP should not be rewritten if nothing has changed for the particular aspect of the problem.

Patient health record
Patient health record

One common mistake that inexperienced physicians make when writing daily progress reports is rewriting the problem under the “Assessment” section in the daily note.

What the physician should do instead, is to give a status report, either using the words “better,” “worse,” or “etiology determined.”

What About a Discharge Summary? What is the POMR Approach to It?

In the discharge summary, the physician should include all the active problems. The physician should define each problem on the problem list comprehensively. Additionally, a symptom overview should be included in the subjective section.

Now:

The objective section contains an analysis of objective results such as lab results and must indicate the likely courses to resolve the problem, which will guide in what to do next.

The main focus of the discharge summary should lie in the problems yet to be resolved. Resolved problems should be written briefly.

How Electronic Medical Records (EMR) Help Execute POMR

In the course of the past three decades, experts in medical informatics have made huge progresses in the development of EMR.

Thanks to technological advancements, it is possible to record all patient information such as clinical documentation, lab tests and imaging studies on electronic records.

EMRs are great because the records are password-protected, unlike paper records. The EMR records are also encrypted and can be transmitted locally within the medical institution and around the world.

Electronic medical records improve patient record accessibility and improve the quality of care
Electronic medical records improve patient record accessibility and improve the quality of care

Why is this important?

Multiple healthcare providers may simultaneously access the records from any computer terminal, meaning that several clinicians will have their eyes on the patient’s record, resulting in improved patient care.

But here is the shocker:

With EMR, there is the problem of cutting and pasting.

Instead of constructing patient documentation from scratch, many physicians cut and paste to the next day and this results in tons of meaningless information pasted into progress notes and discharge summaries.

The cut and paste habit is an abuse of the electronic format and should be condemned.

That’s not all…

Another problem is that the person who copies and pastes the material gives very little thought to what they do, which hinders the evolution of clinical assessment and management.

Physicians should construct each day’s note from scratch, and have appropriate references to existing records.

Demerits of the POMR System. Do They Really Outweigh the Advantages?

The following are some of the disadvantages of the POMR method, which is why it is underutilized:

Healthcare providers understand the system quickly. However, they find it too complex to maintain after entries are made.

Several problems may be discussed by patients in a single medical encounter. This huge amount of information tends to overwhelm healthcare providers.

Another problem is that information may belong to a number of ‘problem’ headings like blood pressure measurements which could easily appear under “hypertension” and “ischemic heart disease.”

There is usually the need to link across entry barriers, which is when one problem is closely linked to or caused by another. For example, pneumonia is a secondary problem that can arise after a prolonged bed confinement due to operations for a broken hip.

The physician may be working within the scope and confinement of the provider’s EHR system.

Using software and hardware reporting capabilities, and working within government-specific reporting constraints may also prevent the doctor from using POMR.

How the Healthcare Sector can Encourage Physicians to Implement POMR

Lawrence Weed, the founder of POMR and his son Lincoln Weed, write in their book Medicine in Denial that healthcare providers should make the effort to adopt the patient-centric approach.

How?

By creating the culture of medicine, where the habits of healthcare providers determine patient care.

Similarly, a paper by the Primary Health Care Specialist Group of the British Computer Society recommends using software designed to help doctors make intelligent decisions with regards to data that can be amended and noted.

Such a system may look for specific notes within a listed problem and create new episodes when such entries are input by the providers.

Conclusion

In this article, we have looked at the POMR medical definition, its advantages and disadvantages.

We have also identified the reason why some physicians love POMR, while others cannot stand it. It is amazing that the POMR approach can result in the creation of precise notes even though it appears to ask a lot from the physician.

The introduction of EMR into the medical industry has helped streamline communication between caregivers in a hospital and the information can be seamlessly shared with practitioners around the world to help solve the medical problems we face.

Doctors should avoid copy-pasting previous records because it adds no value and does not help advance the medical field.

Doctors should create POMR notes every day from scratch and if the patient’s condition has not changed, they should reference the previous day’s notes.

Now it’s your turn. What do you think about POMR? Has this article changed your views, attitude, and approach towards creating medical records? We really would love to hear your opinions in the comments section below.

About the Author:MedConverge

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