Podcast
Questions and Answers
In the context of POMR, what does the 'O' in SOAP stand for?
In the context of POMR, what does the 'O' in SOAP stand for?
- Open-ended
- Objective (correct)
- Observation
- Opinion
Which of the following best describes the primary focus of a Problem Oriented Medical Record (POMR)?
Which of the following best describes the primary focus of a Problem Oriented Medical Record (POMR)?
- Recording billing information for each patient visit.
- Documenting all patient encounters regardless of presenting problem
- Tracking the evolution of a patient's problems and the relationships between clinical events over time (correct)
- Maintaining a chronological list of all treatments administered.
When taking a patient's history, which of the following elements is MOST important to include in the 'Chief Complaint History'?
When taking a patient's history, which of the following elements is MOST important to include in the 'Chief Complaint History'?
- A detailed family history
- The duration and severity of the current problem, using the patient's own words (correct)
- The patient's insurance details
- A complete list of all past medical diagnoses.
Why is it important to start with an open question when eliciting a patient's chief complaint?
Why is it important to start with an open question when eliciting a patient's chief complaint?
A patient mentions experiencing shortness of breath while lying down. In which section of the Review of Systems would this information be MOST relevant?
A patient mentions experiencing shortness of breath while lying down. In which section of the Review of Systems would this information be MOST relevant?
Which element of the POMR is used to determine the effectiveness of the POA (Plan of Action)?
Which element of the POMR is used to determine the effectiveness of the POA (Plan of Action)?
Which of the following reflects a primary focus of the Problem-Oriented Medical Record (POMR)?
Which of the following reflects a primary focus of the Problem-Oriented Medical Record (POMR)?
When gathering information for the database section of POMR, what is the purpose of the Review of Systems (ROS)?
When gathering information for the database section of POMR, what is the purpose of the Review of Systems (ROS)?
If a patient reports a history of hemoptysis, in which section of the Review of Systems should this information be documented?
If a patient reports a history of hemoptysis, in which section of the Review of Systems should this information be documented?
Which of the following is a disadvantage of using a Problem-Oriented Medical Record (POMR) system in a healthcare setting?
Which of the following is a disadvantage of using a Problem-Oriented Medical Record (POMR) system in a healthcare setting?
A patient presents with a chief complaint of a persistent cough, and their history reveals they have asthma. Using the principles of POMR, what is the next step in managing this patient's case?
A patient presents with a chief complaint of a persistent cough, and their history reveals they have asthma. Using the principles of POMR, what is the next step in managing this patient's case?
A 38-year-old male presents with fever, cough, and sputum production. His vitals include a BP of 160/95 mm Hg, HR of 88 BPM, temperature of 38.2°C, and O2 saturation of 99%. Rales are detected during lung auscultation. According to the principles of POMR, what should be included in the problem list?
A 38-year-old male presents with fever, cough, and sputum production. His vitals include a BP of 160/95 mm Hg, HR of 88 BPM, temperature of 38.2°C, and O2 saturation of 99%. Rales are detected during lung auscultation. According to the principles of POMR, what should be included in the problem list?
After formulating an initial plan of action (POA) based on a patient's problem list in a POMR, what is the next critical step to ensure effective patient care?
After formulating an initial plan of action (POA) based on a patient's problem list in a POMR, what is the next critical step to ensure effective patient care?
A patient presents with polyuria, polydipsia, and unexplained weight loss. Which system is MOST likely involved, based on these symptoms?
A patient presents with polyuria, polydipsia, and unexplained weight loss. Which system is MOST likely involved, based on these symptoms?
When closing a history taking encounter with a patient, what is the MOST important step to ensure patient understanding and agreement?
When closing a history taking encounter with a patient, what is the MOST important step to ensure patient understanding and agreement?
During the lung examination component of a physical, which technique involves using your hands to feel for vibrations or abnormalities on the patient's chest wall?
During the lung examination component of a physical, which technique involves using your hands to feel for vibrations or abnormalities on the patient's chest wall?
When documenting a patient's hospital stay, which type of note is typically created on the day the patient is discharged?
When documenting a patient's hospital stay, which type of note is typically created on the day the patient is discharged?
A doctor is evaluating a patient with a suspected neurological issue. Which of the following would be MOST helpful in assessing the patient's motor function?
A doctor is evaluating a patient with a suspected neurological issue. Which of the following would be MOST helpful in assessing the patient's motor function?
When formulating an initial plan of action for a patient's multiple health problems (Problem A, B, and C), what is the MOST logical step after identifying the problems?
When formulating an initial plan of action for a patient's multiple health problems (Problem A, B, and C), what is the MOST logical step after identifying the problems?
During a physical exam, which of the following would be MOST useful in assessing a patient's cognitive function?
During a physical exam, which of the following would be MOST useful in assessing a patient's cognitive function?
A patient presents for a follow-up visit regarding a non-chronic infection. When should the final progress note be documented for this patient?
A patient presents for a follow-up visit regarding a non-chronic infection. When should the final progress note be documented for this patient?
Flashcards
POMR
POMR
Stands for Problem Oriented Medical Record. Focuses on patient problems, their evolution, and relations between clinical events.
Out-Patient
Out-Patient
Non-hospitalized, non-urgent patients who can walk in for treatment.
In-Patient
In-Patient
Hospitalized patients, either scheduled or through the ER.
SOAP
SOAP
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Chief Complaint
Chief Complaint
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Chief Complaint History
Chief Complaint History
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Review of Systems (ROS)
Review of Systems (ROS)
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Patient History Components
Patient History Components
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POMR Advantages
POMR Advantages
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POMR Shortcomings
POMR Shortcomings
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POMR Elements
POMR Elements
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Example findings in a Physical Examination
Example findings in a Physical Examination
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Neurological Symptoms
Neurological Symptoms
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Endocrine Symptoms
Endocrine Symptoms
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Closure of History Taking
Closure of History Taking
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Vital Signs
Vital Signs
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Lung Exam Techniques
Lung Exam Techniques
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Problem List
Problem List
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Initial Plan of Action Elements
Initial Plan of Action Elements
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Discharge Summary
Discharge Summary
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Study Notes
- POMR stands for Problem Oriented Medical Record.
- POMR Created by Lawrence Weed.
POMR focus
- Focuses on patient's problems.
- Includes the evolution of the patient's problems
- Includes correlations between clinical events.
- Longitudinal time frame.
POMR Elements
- Formation of a database.
- Identification of a problem list.
- Formulating an initial plan of action.
- Recording daily progress notes.
- Final progress note or discharge summary to assess plan of action effectiveness.
POMR Breakdown
- P stands for Problem.
- O stands for Objective.
- M stands for Medical.
- R stands for Record.
- V/S (subjective, objective, assessment, plan).
Starting the Process
- Wash your hands.
- Introduce yourself.
- Confirm the patient's identity.
- Determine the patient's position.
Data Base - Chief Complaint
- The chief complaint is what the patient is visiting for.
- Start by posing open-ended questions.
- Use the patient's own terms.
Chief Complaint History
- Includes duration of complaint.
- Includes severity/character of complaint.
- Includes location/radiation of the illness.
- Inquire about any therapeutic maneuvers tried.
- Ascertain the pace of the illness.
- Ask about associated symptoms.
- Find out why they're seeking help today.
Rest of History
- Past medical history.
- Past surgical history.
- Medications (past and present).
- Allergies/reactions.
- Smoking habits.
- Alcohol consumption.
- Family history.
- Work and living environment.
- Pregnancies/obstetrics.
- Sexual activity.
- Drug abuse.
Data Base - Review of Systems
- Consists of a list of questions, organized by organ system.
- Aims to uncover any potential issues.
- Questions should be tailored to the patient, considering factors like age and gender.
- Covers main aspects of patient health.
Review of Systems Examples
- General: weight loss/gain, fatigue, fever.
- H&N: lumps, masses, ulcers, ear issues.
- Pulmonary: hemoptysis, snoring, wheezing, shortness of breath.
- CV: chest pain, DOE, orthopnea, LE edema, palpitations, syncope.
- GI: bleeding, heartburn, abdominal pain, jaundice, difficulty swallowing, stool changes.
- GU: hematuria, burning on urination.
- G-U Breast: masses, pregnancies, sexual activity, discharges.
- Neurological: consciousness, numbness, weakness, headache, balance issues.
- Endocrine: polyuria/polydipsia, unexplained weight loss/gain.
- Infectious diseases.
- Musculoskeletal system.
- Mental health.
- Skin: rashes, itching.
Closing History
- Summarize and reformulate findings for the patient.
- Help confirm findings.
Data Base - Physical Exam
- Involves checking vital signs such as temperature, BP, HR, RR, and O2 saturation.
- Eyes: Assess ocular symmetry, eyelid symmetry, sclera (for yellowish color), conjunctiva, eye movement, visual fields, and conduct fundoscopy.
- Head and Neck: Examine lymph nodes, ears (inspection, otoscope exam, hearing issues), sinuses, oropharynx, and thyroid.
- Lungs: Includes inspection, percussion, palpation, and auscultation.
- Note unusual breathing patterns or sounds.
- Heart: Includes inspection, palpation, and auscultation.
- Listen for unusual chest movements, heart sounds, or murmurs.
- Abdomen: Observation, Auscultation, Palpation, Percussion.
- Checking for abnormal sounds, tenderness, abnormal masses
- Brest Palpation to check, nipple discharge, pain or discoloration
- Extremities: Observation, Palpation
- Look for color changes, deformities, swelling or any peripheral
- Neurologic: Consiousness and Orientation, Cranial Nerves, Sensory and Motor Examinations, Reflex Testing, Coordination and Gait.
Identification of Problem List
- A list of disease conditions that need attention.
Formulating Initial Plan of Action
- Involves determining tests, radiology, and medication.
Progress Notes
- In-Patient: Daily (at least), By Problem, Follows the same principle as the initial note
- Out-Patient: At each follow up visit, By Problem, Follows the same principle
Discharge Summary
- Mainly for in-patients.
- Document created on the day of leaving the hospital.
- Summarizes the general point of the patient's stay since admission.
- Summarizes problem list.
- Summarizes tests done.
- Describes the evolution of the patient.
- Describes the outcome of the hospitalization process.
Final Progress Note/Discharge Summary
- For out-patients.
- Non-chronic diseases: coincides with the timing of cure.
- Chronic diseases: It does not apply.
POMR Flow
- Follows a logical flow: Chief Complaint -> History & Review Systems -> Physical Exam -> Problem List -> Management Plan -> Confirm Diagnosis and Therapy -> Follow Up and Progress Note.
POMR Advantages
- Patient-oriented.
- Easy information access.
- Allows review and revisions of the healthcare plan.
- Reduced inadequate hypothesis generation/misinterpretation of findings.
POMR Shortcomings
- Complex to maintain.
- Time-consuming.
- Repetitive information.
POMR Example scenario
- 38-year-old male presenting with mild fever and cough (5 days).
- Hx reveals mild cough, sputum production.
- Reported diabetes.
- Smokes and Has no family Hx.
- Blood pressure: 160/95 mm Hg.
- Heart rate: 88 BPM.
- Temperature: 38.2; O2 Sat 99%.
- No lymph node enlargement.
- Rales present all over lungs.
Identification of Problem List in Example
- Fever-Cough-Sputum Production-Rales: Bronchitis/Pneumonia.
- Diabetes Mellitus T2.
- Hypertension.
- Smoking.
Initial Plan of Action in Example
- Bronchitis/Pneumonia: Get Blood test, chest X-ray, sputum culture, Initiate drug.
- T2 DM: Get blood test, BUN, urine analysis, keep/adjust treatment.
- Hypertenssion : Blood test, Cr, Urine Analysis, Echocardiography, drug
- Smoking: Lifestyle management and smoking cessation help
Progress Note/Follow Up Note in Example
- Record the status of symptoms, summarize test results, administer tests, adjust according to response for Bronchitis/ Pneunomia, T2DM and Hypertenssion.
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Description
Questions about Problem Oriented Medical Records (POMR) and the significance of subjective, objective, assessment, and plan (SOAP) notes. These questions explore systematic approach to patient care.
