Treatment is the focus of problem-oriented records
Managed care organizations are increasing their focus on clinical procedures. Site visits and chart reviews at many facilities are becoming common, says Jeanne L. Kistner, RRA, director of health information services at Oregon Health Sciences University Hospitals and Clinics in Portland.
Problem-Oriented Medical Records (POMR) work well in reviews because they focus on patient problems and their treatment, Kistner says. Organizationally, the POMR is straightforward, but it does require attention to detail, she adds. For example:
• The record must contain a well-kept problem list.
The list can be found appended either to the right or left side of the paper chart but must be prominently displayed to highlight the patient’s health factors at a glance. Some POMRs also contain a complete medications list.
The problem list identifies the patient’s clinical issues and assigns a reference number to each one. The numbers are then used throughout the chart as shorthand. The use of ICD-9-CM or CPT-4 codes or other descriptors is optional, some records experts say.
But the list must identify social and mental factors such as smoking, unemployment or chronic depression that might affect the patient’s medical condition, says Harry B. Rhodes, MBA, RRA, health information management (HIM) practice manager with the American Health Information Management Association in Chicago.
• The record should highlight the patient’s medical condition.
The record also should be tabbed to include a detailed section containing the patient’s medical and social history, present illness, chief complaint, examination results, and lab data.
In most patient records, documents are filed in no particular order as they come in and are tabbed to emphasize the place of origin of each document such as lab or X-ray rather than a problem. But in the POMR, separately tabbed sections are devoted to the patient’s treatment plan and daily progress notes.
Some POMR advocates also recommend that clinicians and record techs adopt formal headings in the progress notes for subjective and objective observations and space for assessments and solutions to daily problems such as sleeplessness or loss of appetite.
The so-called SOAP-approach (Subjective-Objective-Assessment-Plan) to documentation isn’t popular with everyone, although it does make a paper record easier to read, Rhodes says.
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