Answer:
Step-by-step explanation:
Where & How Did POMR Start?
POMR was introduced in 1968 by Dr. Lawrence Weed.Dr. Weed developed POMR so that “medical students and practitioners could function in a structured, rigorous way more like that of workers in the scientific community” (NCBI).In other words, Dr. Weed intended POMR to serve as a way to standardize the way physicians record and organize patient information.Before POMR, physicians were documenting patient histories in less efficient ways. For example, they would document medical information by source, e.g., x-ray reports in an x-ray section, and lab reports in a section about lab reports, and so on.
However, Dr. Weed opted to organize information in terms of responding to patient problems. So under POMR, Dr. Weed recorded the patient’s information through 5 components:DatabaseThe database contains the patient’s medical history, including their lab results, x-rays, physical exam results, etc.Problem ListThis is a complete problem list outlining the patient’s medical issues after the hospital or clinic admitted them. It will also include information from the database.Initial PlansBased on the problem list, the physician will then write out a complete plan of action for the patient’s care.Daily Progress NotesThe clinic will then update the POMR with the patient’s progress as well as their medical problems (be it one or multiple problems).Discharge SummaryFinally, the discharge summaries will outline the patient’s care over time, i.e., from the point where you admitted them to their stay at the clinic/hospital.Since implementing POMR, the health care community also began using SOAP Notes. Like POMR, a SOAP Note is a standardized documentation method, but between different health care providers or departments working with the same patient.
The SOAP Note comprises of 4 parts:
Subjective:
This component outlines the patient’s main complaint. The physician will also record an HPI (history of present illness), which the patient will describe to the physician. At this point, the physician will listen to the patient for many key details, including:– Negative/Relevant Symptoms– Surgical History– Family Medical History– Current Medications– Drug, Alcohol, & Caffeine Use– Other Factors (e.g., blood pressure).
Objective:
The physician examines the patient’s basic attributes, like weight, vital signs, and measurements. The physician will also note results from lab and diagnostic tests.
Assessment:
At this stage, the physician will outline their observations of the patient’s symptoms and their diagnoses. In a hospital environment with an admitted patient, the doctor will take note of how the patient is progressing following treatment.
Plan:
Finally, the physician will state the next steps for the patient. This step may include assigning treatments, requesting additional tests, or referrals to specialists.
What’s the Benefit of POMR?
POMR was the medical community’s first foray into standardizing patient records and storing it in an electronic format. Since then, POMR has enabled physicians to save time as well as raise the quality of patient care and improve patient satisfaction.For example, with POMR, physicians, and nurses in different departments of the same hospital got a standardized method of reading and updating patient information. Likewise, other clinics and outside consultants could also view the same information in the same way.
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