KAAU ©2007

Contents:

•Objectives.
•The Importance of medical records.
•Organizing medical records.
•What is POMR and what are its main
elements.
•How to form a problem list.
•Components of a medical record
database.
•The Initial plan.
•How to write a progress note.
•Applying the S O A P form.

•Writing medical notes in the form of S O A P.Objectives: •Understanding the importance of organizing medical records. •Understanding the main concept of POMR. . •Knowing how to form a problem list.

•Allows ongoing patient health . •Transferring relevant facts regarding patient care to all health personnel involved.•Permits easy communication between health professionals for optimum patient care.

•Assisting the physician in .• Important for proper assessment of the present health problem. •The management of chronic illnesses requires an accurate dynamic record reflecting past and present medical problems.

g.Organizing medical records Includes/ A proper filing system Organizing each medical record in a systematic way e. applying POMR system. .

especially in terms of quick access and time saving.Organizing medical records using an efficient filing system is of great value. •Alphabetical filing system/ common Misfiling is •Numbering filing system/ common Misfiling is Less •Color coding/ largely eliminated Misfiling is .

. These files should be isolated to prevent misfiling. Records of patients who have not been seen for 2 or 3 years are considered Inactive.Using open shelves is better than closed drawers especially when it is used with the color coding filing system.

beginning with the establishment of a database. and the patient’s progress is monitored. . Initial plans are identified. with continual updating of the database and problem list. after which a problem list is developed.elements Is organizing the medical record of each patient in a logical system.

Initial Plan. . Progress notes.The Four Basic Elements of POMR/ Problem List. Database.

How to form a problem list a problem is anything that requires diagnosis or management or that interferes with quality of life as perceived by the patient. a problem list is a dynamic picture of the patient’s health problem and is changed continually by updating. .

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Active (anything that requires management or further diagnostic workup) 2. resolved medical or surgical illnesses that are still important to be remembered) .Inactive ( problems that are usually prior.The Concept of a Problem List is the single most Important component of POMR. Problems are either: 1.

(depends on degree of understanding) A. or B.Important facts to be noted in constructing a problem list are these: A problem should be defined at its highest level of defensibility. the Problem List could be modified to facilitate more precise (and less lengthy) daily progress notes . list all findings (physical or lab data) as separate problems. list problems according to associability in the second case.

the Problem List must state so.  The Problem List is refined as problems are either resolved or further defined  If the initial data base is incomplete. The Problem List must include all abnormalities noted in the initial data base. .

or "HIGH YIELD" problems are listed first  The MPL should be updated as the case proceeds . the most diagnostically useful. The Positive Review of System  Ideally.

Baseline laboratory studies . Physiologic data. Physical examination. .Components of a medical record database The database is composed of/ Complete history.

. •The database serves as the groundwork for each patient’s future care. •A complete database is so essential to the success of the POMR that many physicians place “Incomplete database” as problem number 1 in the problem list.•The database is the first step toward developing the problem list.

3.The Initial plan •The plan must include 3 distinct groupings : 1. Therapeutic plan. . Patient education plan. Diagnostic plan. •Sometimes the initial plan is incorporated with the progress note . 2.

Progress notes should address each element of the problem list. Plans to treat those problems.How to write a progress note •Well organized and logically structured progress notes in addition to the problem list are the secret of POMR effectiveness in promoting continuing patient care. . •Daily progress notes should summarize developments in all the following/ Patient's hospital course. Problems that remains active.

We use the form S O A P for writing progress notes S: Subjective O: Objective A: Assessment P: Plan .

•e. •State your finding in the physical examination •Include new available lab results.g. •Includes any problem or symptom.S = Subjective / •What the patient states. pain. chest pain. and other symptoms. appetite. vomiting. . nausea. O = Objective / •Always begin with the vital signs.

A & P = Assessment and Plan / It is better to present them together in a list with a separate Assessment and plan for each problem. Assessment  Diagnosis ( If known ) Present status of the problem A diagnosis to rule out Plan Management / o Medication o Procedure o Non pharmacological management  New investigations required  Health education  Assure continuing the previous plan ( If no new plan is needed ) .

HTN: well controlled (or not) on capoten 25 mg Day 2              2. non-tender. non-distended.     O2 sat       Chest: clear to auscultation bilaterally       CVS : regular rate and rhythm S1 + S2 + 0       Abd : positive bowel sounds. Pneumonia: Improving on Zithromax Day 2/5 (This is Day 2 of a 5 day course) SIGN YOUR NAME . no        hepatosplenomegaly)     A/P:              1. O: VS: BP   P   RR   Temp.Applying the S O A P form Example of a S O A P progress note / Date         Time       HD (Hosp. Day) #2 or POD (post-op day) # 2 post appendectomy S: Pt c/o three episodes of chest pain associated with nausea and vomiting.

S O A P can also be used in the following/ Writing short case reports. Writing patient’s discharge plan. Presenting cases in rounds .

Database. •POMR is a perfect system for organizing medical records. •All elements of POMR should be completed including: The problem list. Initial plan and progress notes. •Well organized progress notes and problem list are the secret of an effective POMR system. .Summary •Medical record should be well organized to Permits easy communication between health professionals for optimum ongoing patient’s health care.

Physical examination and lab results.•You must have a complete and accurate problem list for each patient. •Always update the record’s database and problem list according to the progress notes. •Complete the patient’s record database with proper history. . •Summarize the patient’s daily health status development in a proper S O A P progress note.

Thank You Done by: Zahir T Fadel KAAU ©2007 .