Question

A hospital unit maintains documentation in the form of a problem-oriented medical record (POMR). The nurse notices that a patient reports symptoms of acid reflux. On further assessment, the nurse finds that the patient has fully recovered from typhoid. Where and how does the nurse update the record? Select all that apply.

a) Add the new problem to the problem list of the patient.

b) Highlight typhoid and add the date of recovery.

c) Highlight reflux and add the date of the occurrence of the sign.

d) Remove the old progress note and add a new one with updates.

e) Add a new admission assessment along with the existing records.

Answer 1

To update the problem-oriented medical record (POMR), the nurse should add the new problem of acid reflux to the patient's problem list, highlight the previous problem of typhoid and add the date of recovery, highlight the new problem of acid reflux and add the date of its occurrence, and add a new progress note with updates.

Step-by-step explanation:

To update the problem-oriented medical record (POMR) in this scenario, the nurse should take the following steps:

1. Add the new problem of acid reflux to the patient's problem list.
2. Highlight the previous problem of typhoid and add the date of recovery.
3. Highlight the new problem of acid reflux and add the date of its occurrence.
4. Do not remove the old progress note, but add a new one with updates reflecting the recovery from typhoid and the occurrence of acid reflux.

These steps ensure that the POMR accurately reflects the patient's current health status and history.