Understanding and Reviewing POMR, the Problem Oriented Medical Record
Medical records have a very important role to play when it comes to the delivery of medical services to a patient. A well-documented medical chart provides a complete and accurate patient history to all treating physicians and thereby helps to improve patient care. The medical record is a legal document and comprehensive medical record review is an important process in medical negligence and personal injury cases. Attorneys have to organize, index, summarize and review the injured person’s medical records to find out the strengths and weaknesses of a case. Medical records also play a very important role in determining eligibility for social security disability insurance and other insurance coverage. It is essential that medical documentation is complete, legible and timely. This means that the medical chart of a patient should record the history of the patient, physical findings, evaluation of the findings, plan for treatment, details of healthcare services provided, progress report and so on. There are many methods in which patient details can be documented. Here we examine one such method of documentation or charting, Problem Oriented Medical Record (POMR) that attorneys may encounter when reviewing medical records for legal purposes.
Documenting Medical Details in a Problem-solving System The POMR method focuses on recording the data in an easily accessible way that enables easy analysis and modification of the health care plan by all members in a healthcare team. The specific format of this system may vary from one healthcare setting to another, though the components of the method are the same. Before beginning to identify the patient’s problems, the first step is the creation of a database that will contain all information available regarding the patient’s health condition, injuries/illnesses, and related problems. Apart from the patient’s own history and physical examination results, this database will also contain details regarding family illness history. The second section of the POMR is the master problem list, wherein each problem identified signifies a conclusion or a decision that has been taken following examination, investigation and evaluation of the database. These problems may range from physical abnormalities to psychological issues and socioeconomic problems. In fact, this is an important section that should list all current, past, temporary and potential problems of the patient. Here you can expect to find a chronologic list of problems, with details regarding the date of each problem’s onset; the action taken/treatment provided; the results and the date of the outcome. Problems may be added to this section as they appear, and the treatment/intervention or treatment plans may be changed and recorded accordingly.
Now we come to the third important section of the POMR, which is the initial plan wherein each problem is named and elaborated, usually on the progress note in SOAP format. In this format, S – subjective data from the point of view of the patient; O – objective data gathered from detailed examination and the results of lab and imaging tests; A – assessment of the problem that comprises an analysis of the subjective and objective data; and P – plan that includes further diagnostic tests, therapy, and counseling/education. Once an initial plan for each problem is drawn up and recorded, the problems are followed in the progress notes by narrative notes in SOAP format or flow sheets displaying the important data in a tabular manner. A discharge summary is then prepared and written that would contain an overall assessment of the patient’s progress during treatment and the plans for follow-up treatment or referral. From a medical point of view, the summary facilitates a clear appraisal of all the problems identified initially and helps in providing continued care for the patient.
Medical Record Review Services to Lighten the Review Process Attorneys and their paralegals may find it challenging to decide whether a medical record is thorough. Only a person with medical training and a professional eye for significant medical details can ensure that a medical chart is complete. Medical review services can prove to be excellent support for attorneys engaged in medical litigation. Trained professionals would look for the minutest details when reviewing the records and determining whether the services delivered were appropriate for the condition of the patient. They would look for entries such as: The reason for the patient encounter Evaluation of the condition of the patient All action taken including services delivered Test/treatment results Continued care plan
Whether or not the provider obtained informed consent from the patient Details of telephone calls between the provider and patient Details regarding missed appointments Follow-up details and patient reminders if any All these may become significant in a personal injury case, and these are details an attorney untrained in medical matters may miss or overlook. Sensing the necessity of insightful medical record review, legal professionals use the services of a good medical record review company to save time and effort, and most importantly to ensure that they have all the medical facts they need at their fingertips.
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