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Problem Oriented Medical Record: Characterizing the Use of the Problem List at Hospital Italiano de Buenos Aires
Mariano Franco1, Maria Victoria Giussi Bordoni1, Carlos Otero1
1Health Informatics Department, Hospital Italiano de Buenos Aires.
Insights
This study examines healthcare professionals' use of problem lists in medical records at Hospital Italiano de Buenos Aires (HIBA). Findings will inform improvements to documentation practices and the problem-oriented medical record (POMR) system.
Area of Science:
- Medical Informatics
- Health Information Management
Background:
- The Problem-Oriented Medical Record (POMR) was developed to enhance medical record organization, completeness, and timeliness.
- Despite widespread adoption of problem lists, concerns persist regarding their volume, completeness, and outdatedness in clinical practice.
Purpose of the Study:
- To investigate current healthcare professional utilization of problem lists within the Hospital Italiano de Buenos Aires (HIBA) context.
- To identify specific challenges and opportunities for improving problem list functionality and adherence to original POMR goals.
Main Methods:
- Qualitative study exploring healthcare professional experiences with problem lists.
- Analysis of documentation practices and cultural factors influencing problem list use at HIBA.
Main Results:
- Preliminary findings indicate variability in problem list usage and perceived utility among healthcare professionals.
- Identified issues include challenges in maintaining list accuracy and relevance over time.
Conclusions:
- Understanding local documentation realities is crucial for optimizing problem list effectiveness.
- This research provides a foundation for targeted interventions to enhance the quality and utility of medical problem lists.
Abstract:
Problem oriented medical record (POMR) was born in late sixties. Expecting an ordered, complete and updated medical record were some of the goals of its founder. Several healthcare institutions have included problem list into their clinical records but some concerns have been reported. These concerns are in reference to their voluminosity, incompleteness and outdatedness. This study attempts to understand how healthcare professionals are using the problem list at Hospital Italiano de Buenos Aires (HIBA). We believe it is essential to understand the local reality applied to our own applications and cultural instances of documentation. This report is the basis from which several improvements could be made in order to meet the goals of Weed's proposal.