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Published on: January 8, 2020

The effect of problem-oriented medical records on clinical management controlled for patient risks

L C Fernow, C Mackie, I McColl

    Medical Care
    |June 1, 1978
    PubMed

    Insights

    Problem-Oriented Medical Records (POMR) may enhance clinical management thoroughness. This study compared firms using POMR to those not, finding potential improvements in patient care across several diseases.

    Area of Science:

    • Health Services Research
    • Clinical Informatics
    • Medical Record Management

    Background:

    • The implementation of new medical record systems can impact clinical practice.
    • Understanding the effects of Problem-Oriented Medical Records (POMR) on management is crucial for healthcare quality improvement.

    Purpose of the Study:

    • To evaluate the impact of introducing Problem-Oriented Medical Records (POMR) on clinical management practices.
    • To compare management changes in firms utilizing POMR versus those not using it.

    Main Methods:

    • Analysis of clinical management changes in 28 medical and surgical firms across three London teaching hospitals.
    • Utilizing a regression model to analyze changes between study years, adjusted for patient variables.
    • Comparing firms that adopted POMR with those that did not.

    Main Results:

    • Results were not conclusive but suggested potential improvements in management thoroughness for four out of seven diseases studied.
    • Identified significant patient variables (physiological, demographic) associated with disease management.
    • Highlighted the influence of patient risk on admission on management scores.

    Conclusions:

    • POMR may offer benefits in improving the thoroughness of patient management.
    • Patient characteristics significantly influence management scores, suggesting risk stratification is important.
    • Future comparisons between hospitals should account for patient mix variations.

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