IVMS ICM-Problem Orientated Medical Record (POMR)

1. Problem Orientated Medical Record (POMR)
Marc Imhotep Cray, M.D.
For: IVMS ICM-Physical Diagnosis PowerPoints and Notes
Source/modified from:
http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/subint/pomrfinal.htm
Problem Orientated Medical Record (POMR)
The POMR as initially defined by Lawrence Weed, MD, is the official method of record keeping
use by most medical centers and thus in most undergraduate medical schools. Many
physicians object to its use for various reasons - it is too cumbersome, inhibits data
synthesis, results in lengthy progress notes, etc. However, the proper use of the POMR does
just the opposite and results in concise, complete and accurate record keeping. A brief
overview of the salient features of the POMR will be helpful.
The basic components of the POMR are:
1. Data Base - History, Physical Exam and Laboratory Data
2. Complete Problem List
3. Initial Plans
4. Daily Progress Note
5. Final Progress Note or Discharge Summary
Note: 1, 2 and 3 above must be completed by the admitting physician.
DATABASE
The importance of the Data Base is obvious and must include a complete history and physical
exam. Many hospitals include certain routine laboratory studies (CBC, SMAC, EKG, chest x-
ray, urinalysis, etc.) for each patient admitted. If these are available to the admitting
physician, they are to be included in the initial data base along with a history and physical. As
additional information is collected it is added to the Data Base.
COMPLETE PROBLEM LIST
After the admitting physician performs the history and physical, reviews the basic laboratory
data and records the data base, the Problem List is constructed and recorded. The
construction of a Problem List is the initial step (for the next step, see number 3 - Initial
Plans) of what physicians "really do". That is, once they have seen the patient, physicians
IVMS-ICM/MIC/10/11 Problem Orientated Medical Record (POMR)

2. think about and define "what is wrong with the patient" or "what are this patient's problems."
Problems are either active or inactive (inactive problems are usually prior, resolved medical
or surgical illnesses that are still important to be remembered). Dr. Weed had defined an
active problem as anything that requires management or further diagnostic workup.
Physicians often get caught up in defining Problems and Problem Lists, accusing each other of
lumping, splitting, etc. This is unnecessary. Important facts to be noted in constructing a
problem list are these:
A. A problem should be defined at its highest level of defensibility. Consider, for example,
a beginning medicine clerk who admits a patient with vomiting and confusion. On
physical exam the patient is found to have muscle twitching and a pericardial friction
rub. The initial lab data reveals a BUN of 100 and potassium of 7.0. The student lists
each of these abnormalities as a separate problem. This listing of six problems tells us
that the beginning student does not recognize that all of these are manifestations of
one problem, uremia. A second-year resident might have recorded the Problem List as
having only one problem, uremia, and included all the other abnormalities under that
problem. Both Problem Lists are acceptable. The second-year resident is merely
reflecting a higher degree of understanding. The following day the clerk's Problem List
could be modified to facilitate more precise (and less lengthy) daily progress notes.
Date Problem
Prob.# Problem List
Entered Resolved
1 5/2/84 BUN 5/3 uremia
2 5/2/84 K 5/3 See #1
3 5/2/84 Muscle twitching 5/3 See #1
4 5/2/84 Pericardial friction rub 5/3 See #1
5 5/2/84 Vomiting 5/3 See #1
6 5/2/84 Confusion 5/3 See #1
Resolving problem 2-6 under 1, uremia, allows one daily progress note to be written for that
problem and tells an observer reading the patient's chart that all the signs and symptoms in
problems 2-6 are related to manifestations of uremia. The date 5/3 tells the observer to see
the notes of that day to explain the redefining of the Problem List.
B. The Problem List must include all abnormalities noted in the initial data base. Again,
each abnormality need not be separately recorded (see above example).
C. The Problem List is refined as problems are either resolved or further defined.
1. Example--Problem Resolved: A patient is admitted with a fever and cough
productive of yellow sputum which on Gram stain reveals Gram positive
intracellular diplococci. The patient is treated for seven days with penicillin and
the patient's problem clinically and radiologically resolves.
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3. Date Problem
Prob.# Problem List
Entered Resolved
pneumococcal pneumonia
1 5/2
5/9
The date 5/9 refers an observer to that date's progress note which will explain why the
problem is considered resolved.
2. Problem Further Defined: Consider the first example of the patient with uremia. On day
5/7 a renal biopsy is done which reveals the etiology of the renal failure. The Problem
List would then show:
Date Problem
Prob.# Problem List
Entered Resolved
BUN 5/3 Uremia 5/7 Secondary
1 5/2 to membranous
glomerulonephropathy
Again the date of 5/7 will refer the reader to the progress note for that day which should
reveal the result of the renal biopsy.
D. If the initial data base is incomplete, the Problem List must state so.
Example: A female patient who is admitted with upper GI bleeding has not had a pelvic exam
in 2 years. A pelvic and Pap Smear are not done on admission because the patient is
unstable. The problem list must include a problem that states
Date
Prob.# Problem List Problem Resolved
Entered
Incomplete Data Base
2 5/2
Pelvic/Pap Not Done
Once the patient is stable and the pelvic exam/Pap smear is done, the problem is resolved.
Date Problem
Prob.# Problem List
Entered Resolved
Incomplete Data Base
Pelvic/Paps
2 5/2 5/9
Done-Normal
Pelvic/Paps Not Done
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4. E. The Positive Review of Systems: Many physicians wonder what to do with the patient
who answers affirmatively for every question asked in the review of systems. Does
each positive have to be recorded separately? Obviously not!
Example: For an elderly, lonely female who is admitted with a hip fracture and whose
physical exam is normal except for the hip and whose answers are positive for every question
asked in the review of systems, the physician could list the problems: #1 - Fracture left hip,
and #2 - Positive review of systems. Or, recognizing that all these affirmatives may be
manifestations of depression, the physician could list #2 - Depression.
INITIAL PLANS
The next process that a physician undertakes after deciding "what is wrong" is "what to do
about what is wrong." This is the initial plan and must be written by the admitting physician
after the Problem List is constructed.
For each problem defined, a SOAP note must be recorded.
The Subjective and the Objective are each a brief review of the abnormalities identified in the
history, physical, and initial lab data, which pertain to that particular problem. These need not
be lengthy, but simply one or two lines reviewing the pertinent data.
The Assessment is a brief but pertinent paragraph describing what the physician thinks about
that particular problem. If the problem recorded is a sign or symptom requiring a differential
diagnosis, the DDx must be recorded in a prioritized manner with a brief statement as to why
the physician includes the differential that he or she does. If the problem is a known
diagnosis (example - asthma), the physician must include in the Assessment a statement that
describes the severity and why the problem has worsened requiring admission to the
hospital.
The Plan must include three distinct groupings:
i. Diagnostic Plan: The diagnostic plan includes all the diagnostic workup which
the admitting physician feels will be necessary. If the Assessment includes the
differential diagnosis, then each must be ruled in or ruled out in the diagnostic
plan. This may be done by way of a Venn diagram. Consider a 23 year-old
female admitted with pleuritic chest pain for which the admitting physician
includes pulmonary embolus, pericarditis, or viral pleuritis in the differential
diagnosis. The diagnostic plan may be as follows:
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5. If the problem is a known diagnosis, then the diagnostic plan must include additional workup
needed either to further define the problem or to assess the severity of the problem.
ii. Therapeutic Plan: Must detail all initial therapies started and their rational.
iii. Patient Education Plan: Details the initiation of plans to educate the patient of
what the problem is and how the patient will deal with it in the future.
DAILY PROGRESS NOTES
Many physicians object to the POMR because its use results in lengthy, redundant progress
notes. However, when used properly, the POMR does just the opposite and results in notes
that are clear, direct, brief and complete. A few helpful hints regarding the progress notes
are:
A. A note for each active problem identified need not be written every day. If nothing has
changed regarding a particular problem, a note for that problem need not be written.
An observer will refer back to the prior day=s note to get a progress report on that
particular problem.
B. The S, O, A, or P need not be rewritten if nothing is changed for that particular aspect
of the problem.
C. A common error in writing daily progress notes concerns restating the problem under
the Assessment in the daily note. Example: If the problem is congestive heart failure,
the Assessment for that particular problem on any day cannot be "congestive heart
failure." This is simply a restatement of the problem. However, the physician must give
a status report (example - better, worse, or etiology determined) under the
assessment.
FINAL PROGRESS NOTE OR DISCHARGE SUMMARY
The final progress note should include all active problems, each defined as to its furthest
resolution on the Problem List. The Subjective should include a brief review of the course of
symptoms. The Objective should review the course of objective parameters. The
Assessment and Plan should include the probable course to follow and define end-points as a
guide for further therapy. The emphasis on the final progress note should be the unresolved
problems. Problems which are resolved can be written up briefly.
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6. REFERENCES
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