Problem-oriented files are making a comeback
Underscoring patient problems aids automation
After languishing for years in disfavor from both clinicians and health information managers, the much maligned problem-oriented medical record (POMR) may be coming back.
Two factors fueling its return are managed care and computerization. Some HIM experts are advising managers to consider a POMR approach when pursuing managed care contracts and when converting to electronic patient records.
The POMR was once considered an overly formal method which created extra work for physicians by requiring too much detail. Treatment plans and progress notes had to be carefully written and stored in the chart according to strict rules. (For a description of how to set up a POMR, see related story, below.)
Today, information managers are taking a second look at the problem-oriented record, says Jeanne L. Kistner, RRA, director of health information services at Oregon Health Sciences University Hospitals and Clinics in Portland. Here’s why:
• Managed care organizations are insisting on tougher documentation standards.
Payers are closely scrutinizing how providers are compiling diagnosis and treatment information on their enrollees. Payers are especially concerned about how providers are tracking patients who rack up numerous outpatient visits in a single year, Kistner says.
The record’s standards mirror those endorsed by national accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, Kistner adds.
The Joint Commission has adopted elements of the POMR, such as the use of itemized listings that summarize patients’ clinical problems and medications on separate sheets in the paper file.
"Clinicians who once disliked the formality of [the POMR] now find that they have to conform," Kistner says.
• Automation, the other key factor, has enabled HIM departments to use the POMR approach with greater ease than in the past, says Harry B. Rhodes, MBA, RRA, HIM practice manager with the American Health Information Management Association in Chicago.
Unlike the Source-Oriented Medical Record, a system that divides documents by origin such as lab or X-ray, the POMR forces you to think in terms of the treatment process, Rhodes says. The computerized record is perfectly suited for organizing files according to the patient’s problems and their occurrence, he adds.
The POMR enables the reader to search through dates and indexes quickly or to call up documents without having to leaf through layers of paper. In most POMRs, the diagnoses and treatment notes are ranked in chronological order.
Using a POMR format allows clinicians to write and edit their notations on the computer and makes it easy for technicians to save and locate documents by dates or reference numbers. Instead of making paper charts obsolete, computerization has actually revived the utility of the traditional POMR, Rhodes says.
However, the problem-oriented record isn’t useful in all outpatient settings. It is best applied when patients are seen over a long time period. The POMR is extremely useful, for example, in family practice settings or physical rehabilitation.
It is not effective in urgent or episodic care such as hospital emergency departments "where patients generally receive treatment once and aren’t likely to return," Rhodes says.
• Harry B. Rhodes, HIM Practice Manager, American Health Information Management Association, 919 N. Michigan Ave., Suite 1400, Chicago, IL 60611-1683. Telephone: (312) 787-2672, Ext. 330. Fax: (312) 787-5926. E-mail: [email protected].
• Jeanne L. Kistner, Director of Health Information Services, Oregon Health Sciences University Hospitals and Clinics, 3181 Southwest Sam Jackson Park Road, GH113, Portland, OR 97201. Telephone: (503) 494-5111. Fax: (503) 494-4298. E-mail: [email protected].
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