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While POMR heads the Syllabus for the teaching of medical
history taking, most first year medical students encounter a source oriented
format or at best a hybrid system without ever learning the problem oriented
system, a system first promoted by Larry Weed at Dartmouth in the early
sixties. In truth, the hybrid system of charting a patient's medical history
and progress, may be superior in that, including the source oriented, or more
traditional, style better identifies the full character of the patient as seen
through the physician's eyes. Tradition since Hippocrates tells us that
"if you just listen," the patient will tell you everything you need
to know. The traditional chief complaint, history of the present illness, past
medical history, social and family history followed by a complete review of
systems constitutes the source oriented medical history. The medical history is
a story, with color, pathos, complication, progression, humanity and hopefully,
with your guidance, a resolution. It is a story worth telling and worth telling
well. Both the patient and physician will likely evolve in so doing.
The POMR, however, represents a far better way to organize information when there are multiple problems. For instance, for an older patient who might have a dozen or more concurrent, problems, some undiagnosed, some controlled and some resolved, the problem list brings together all of the concurrent problems. The POMR lists the patient's problems as a table of contents, numbering each problem, dating the identification of the problem and dating its resolution. The two dates are critical in referencing the place in the progress notes where and by whomever the problem was identified and the strategy outlined in the SOAP note for diagnosing and treating the problem.
POMR, furthermore, helps with diagnosis, listing all the problems in one place, exposing their potential relationships and synergisms, opening a window to greater understanding of one patient's struggle with disease and his or her environment. Problems get lost in the time constraints of employed providers. A positive response on the (ROS) review of systems is by definition a problem worthy of placement on the problem list, yet problems get dropped, lost, forgotten, never to be seen by subsequent team members. One could therefore argue that the problem list is the most important but often least understood page on the patient's chart.
The SOAP note then describes the subjective information derived from the patient as well as the intuitions of the physician in a stylized format followed by objective data, an assessment of the condition and finally a plan to move forward. Larry Weed, he's now in his 90s living in Vermont, insisted on including a rationale and the goals you expect to achieve.
Thus:
# - Problem
S: subjective
O: objective
A: assessment
P: plan
The POMR oriented patient history consists of a series of SOAP notes: indexed to the problem list, replacing the traditional Chief Complaint and Present Illness, written in numeric order and positioned at the beginning of the patient history. The rest of the traditional source oriented history may follow or in the case of the POMR purist, included in the initial numbered SOAP format in the initial patient history.
Daily progress notes then follow in the same SOAP note format rationalizing every laboratory test and medication order - this in sharp contrast to the typically thick hospital chart in which the orders written have little or no relationship to the progress note or indeed the problem for which the order was written. With multiple specialists dealing with one patient, the organizational advantages of the POMR seem obvious.
An individual physician's own hybrid version combining the POMR with the narrative of the traditional source oriented history promises the best of both worlds. However, the advent of the (EHR) electronic health record, makes a very loose structure out of either the POMR or source oriented system. There may be no way to write a program that will accommodate all patients and all doctors. The POMR does, however, lend itself rather well to the structured format of the EHR, but only if it accommodates a narrative and tells the story in supporting either the source oriented or POMR system or indeed the hybrid which should be taught. Voice recognition would seem essential in allowing the story to be told quickly and in depth.
Now more than ever, the so called medical home, teaching hospital or multispecialty clinic depends upon a high quality medical record to paint a true picture of the patient, the patient's environment, their problems and relationships in order to build a differential diagnosis or to explore the subtle underlying causalities.
The POMR, however, represents a far better way to organize information when there are multiple problems. For instance, for an older patient who might have a dozen or more concurrent, problems, some undiagnosed, some controlled and some resolved, the problem list brings together all of the concurrent problems. The POMR lists the patient's problems as a table of contents, numbering each problem, dating the identification of the problem and dating its resolution. The two dates are critical in referencing the place in the progress notes where and by whomever the problem was identified and the strategy outlined in the SOAP note for diagnosing and treating the problem.
POMR, furthermore, helps with diagnosis, listing all the problems in one place, exposing their potential relationships and synergisms, opening a window to greater understanding of one patient's struggle with disease and his or her environment. Problems get lost in the time constraints of employed providers. A positive response on the (ROS) review of systems is by definition a problem worthy of placement on the problem list, yet problems get dropped, lost, forgotten, never to be seen by subsequent team members. One could therefore argue that the problem list is the most important but often least understood page on the patient's chart.
The SOAP note then describes the subjective information derived from the patient as well as the intuitions of the physician in a stylized format followed by objective data, an assessment of the condition and finally a plan to move forward. Larry Weed, he's now in his 90s living in Vermont, insisted on including a rationale and the goals you expect to achieve.
Thus:
# - Problem
S: subjective
O: objective
A: assessment
P: plan
The POMR oriented patient history consists of a series of SOAP notes: indexed to the problem list, replacing the traditional Chief Complaint and Present Illness, written in numeric order and positioned at the beginning of the patient history. The rest of the traditional source oriented history may follow or in the case of the POMR purist, included in the initial numbered SOAP format in the initial patient history.
Daily progress notes then follow in the same SOAP note format rationalizing every laboratory test and medication order - this in sharp contrast to the typically thick hospital chart in which the orders written have little or no relationship to the progress note or indeed the problem for which the order was written. With multiple specialists dealing with one patient, the organizational advantages of the POMR seem obvious.
An individual physician's own hybrid version combining the POMR with the narrative of the traditional source oriented history promises the best of both worlds. However, the advent of the (EHR) electronic health record, makes a very loose structure out of either the POMR or source oriented system. There may be no way to write a program that will accommodate all patients and all doctors. The POMR does, however, lend itself rather well to the structured format of the EHR, but only if it accommodates a narrative and tells the story in supporting either the source oriented or POMR system or indeed the hybrid which should be taught. Voice recognition would seem essential in allowing the story to be told quickly and in depth.
Now more than ever, the so called medical home, teaching hospital or multispecialty clinic depends upon a high quality medical record to paint a true picture of the patient, the patient's environment, their problems and relationships in order to build a differential diagnosis or to explore the subtle underlying causalities.
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