The Pomr Medical Record Divides The Chart Into Four Parts
Medical records are an essential part of the healthcare system. They contain all the information about a patient's health history, diagnosis, treatment, and follow-up. The POMR (Problem-Oriented Medical Record) is a method of medical record-keeping that divides the chart into four parts, making it easier for healthcare providers to manage and organize patient information.
POMR: What is it?
The POMR method was first introduced by Dr. Lawrence Weed in the 1960s. It is a way of organizing medical records, making it easier for healthcare providers to understand a patient's health history, diagnosis, treatment, and follow-up. The POMR divides the chart into four parts: database, problem list, plan, and progress notes.
Database
The database is the first part of the POMR. It contains all the patient's medical information, including their medical history, physical examination, diagnostic test results, and other relevant information. This information is used to create a complete picture of the patient's health status.
Problem List
The problem list is the second part of the POMR. It contains a list of all the patient's current and past medical problems. Each problem is listed separately, along with the date of onset, severity, and any relevant diagnostic test results. This helps healthcare providers to track a patient's progress and identify any potential issues.
Plan
The plan is the third part of the POMR. It contains the healthcare provider's plan of action to address the patient's medical problems. This can include medication, surgery, therapy, or any other treatment plan. The plan is updated regularly as the patient's condition changes.
Progress Notes
The progress notes are the fourth part of the POMR. They contain a record of the healthcare provider's interactions with the patient, including any changes to the plan, updates on the patient's condition, and any other relevant information. Progress notes are updated regularly and provide a complete picture of the patient's health status.
Benefits of the POMR
The POMR method has several benefits. It allows healthcare providers to organize and manage patient information efficiently, making it easier to track a patient's progress and identify potential issues. It also promotes collaboration between healthcare providers, as each provider has access to the same information. Additionally, the POMR method improves the quality of patient care, as healthcare providers can make informed decisions based on a complete picture of the patient's health status.
Conclusion
The POMR method is an effective way of organizing medical records, making it easier for healthcare providers to manage and track patient information. By dividing the chart into four parts, the POMR method promotes collaboration between healthcare providers, improves the quality of patient care, and ensures that all patient information is organized and up-to-date.