Format review: evaluating implementation of the problem-oriented medical record

Area of Science:

• Medical Informatics
• Healthcare Administration
• Clinical Documentation

Background:

• Growing interest in the problem-oriented medical record (POMR) necessitates evaluation of its adoption and effectiveness.
• Healthcare settings implementing POMR require methods to document program success and address challenges.

Purpose of the Study:

• To introduce and explain the format review technique for assessing POMR implementation.
• To demonstrate how format review can identify patterns and difficulties in POMR usage.

Main Methods:

• Format review involves examining patient records concurrently with patient care.
• Data from record reviews are summarized to identify POMR usage patterns and areas needing improvement.

Main Results:

• The format review technique provides an overview of POMR use patterns.
• It effectively identifies specific difficulties and obstacles encountered during POMR implementation.
• Application at Michael Reese Hospital and Medical Center over two years validated its utility.

Conclusions:

• Format review is a valuable tool for describing POMR implementation progress.
• Findings from format review can inform targeted educational and administrative interventions.
• This technique supports continuous improvement in the use of the problem-oriented medical record.