A psychiatric POMR for use by a multidisciplinary team

Area of Science:

• Medical Informatics
• Psychiatric Healthcare Management
• Health Information Systems

Background:

• The Fairfield Hills Hospital medical record system required revision due to evolving multidisciplinary team structures.
• Challenges in meeting Medicare standards necessitated an updated patient record system.
• Existing documentation methods hindered equitable shared responsibility in patient care.

Purpose of the Study:

• To introduce and describe a novel psychiatric problem-oriented medical record (POMR) system.
• To facilitate improved documentation and collaboration for multidisciplinary teams in psychiatric settings.
• To address deficiencies in patient record systems related to team-based care and regulatory compliance.

Main Methods:

• Development and implementation of a comprehensive problem-oriented medical record (POMR) system.
• Design of various forms integrated into the POMR system for structured data collection.
• Utilization of regularly scheduled multidisciplinary team conferences for form completion and patient record management.

Main Results:

• Successful introduction of a problem-oriented medical record (POMR) system tailored for psychiatric care.
• The POMR system supports the documentation needs of multidisciplinary teams.
• The new system aids in addressing challenges related to Medicare standards and shared patient care responsibilities.

Conclusions:

• The implemented psychiatric problem-oriented medical record (POMR) system effectively supports multidisciplinary team functioning.
• This approach enhances patient record management in psychiatric facilities.
• The POMR system provides a framework for meeting evolving healthcare standards and team-based care models.