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The problem-oriented medical record: modification and simplification for rehabilitation medicine
Southern Medical Journal
|November 1, 1977
Summary
A modified medical record system enhances rehabilitation medicine by categorizing patient issues and improving team communication. This approach aims to boost patient care, medical education, and audit processes.
Area of Science:
- Rehabilitation Medicine
- Medical Informatics
Background:
- The traditional Problem-Oriented Medical Record (POMR) system requires adaptation for specialized fields like rehabilitation medicine.
- Integrating structured data collection and team-based approaches is crucial for effective patient management.
Observation:
- A modified POMR system was developed, incorporating the Weed system's principles.
- Rehabilitation problems are systematically categorized into seven functional areas.
- The system utilizes a modified problem-oriented progress note format.
Findings:
- The enhanced POMR includes a problem-oriented team conference structure.
- A dedicated functional status form is integrated into the patient record.
- Key modifications focus on improving the documentation and communication of patient progress.
Implications:
- The modified POMR is expected to enhance the quality of patient care in rehabilitation settings.
- Improvements in medical education are anticipated through structured documentation and team interaction.
- The system is designed to facilitate more efficient and effective medical audits.