What are Problem Oriented Medical Records (POMR)?
Problem Oriented Medical Records (POMR) is a structured method of documentation that focuses on the patient's specific health problems. This approach organizes information in a way that makes it easier for healthcare providers to identify, track, and manage these problems systematically. POMR is widely used in nursing to enhance
communication among caregivers, improve care coordination, and ensure comprehensive and continuous care.
Components of POMR
POMR typically consists of several key components: Database: This initial section includes the patient's history, physical examination findings, and diagnostic test results. It serves as the foundation for identifying current and potential problems.
Problem List: A concise list of the patient's active, inactive, and resolved problems. Each problem is assigned a unique number for easy reference.
Initial Plan: This outlines the diagnostic, therapeutic, and patient education plans for each identified problem.
Progress Notes: These are ongoing notes that track the patient's progress concerning each problem. They are often formatted using the
SOAP method (Subjective, Objective, Assessment, Plan).
Improved Organization: By structuring information around specific problems, POMR helps nurses quickly locate relevant data and updates.
Enhanced Communication: POMR facilitates better communication among healthcare team members by providing a clear and consistent format for documenting patient issues.
Continuity of Care: The systematic approach of POMR ensures that all patient problems are monitored and managed over time, promoting continuity of care.
Accountability: POMR assigns responsibility for each problem, making it easier to track interventions and outcomes.
Comprehensive Documentation: POMR encourages comprehensive and detailed documentation, which is crucial for legal and quality assurance purposes.
Challenges in Implementing POMR
Despite its benefits, POMR can present some challenges: Time-Consuming: The detailed documentation required can be time-consuming, especially in busy healthcare settings.
Training Requirements: Effective use of POMR requires training and familiarity with the system, which can be a barrier for some nurses.
Consistency: Ensuring consistency in how problems are identified and documented can be challenging, particularly in multidisciplinary teams.
Adaptation to Electronic Health Records (EHRs): Integrating POMR into EHR systems can be complex and may require additional customization.
Training Programs: Implement comprehensive training programs to ensure that all staff are proficient in using POMR.
Streamlined Documentation Processes: Develop templates and guidelines to streamline the documentation process and reduce the time burden on nurses.
Regular Audits: Conduct regular audits to ensure consistency and accuracy in problem identification and documentation.
Integration with EHRs: Work closely with EHR vendors to integrate POMR features and ensure seamless functionality.
Conclusion
Problem Oriented Medical Records (POMR) offer a structured and systematic approach to patient care that can significantly enhance nursing practice. By focusing on specific patient problems, POMR improves organization, communication, and continuity of care. While there are challenges in implementing POMR, these can be addressed through training, streamlined processes, regular audits, and effective integration with electronic health records.
