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Methods of Documentation II: POMR

Methods of Documentation II: POMR

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.

Methods of Documentation I: Source-Oriented Records

Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:

Purpose of Health Records I

Purpose of Health Records I

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:

Purpose of Health Records II

Purpose of Health Records II

Health records serve various essential purposes in the healthcare system. Here are some key purposes:

Methods of Documentation VII: EMR

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...

Introduction to Documentation and Reporting

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...

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Published on: March 19, 2018

Addendum: Building a Shared, Scalable, and Sustainable Source for the Problem-Oriented Medical Record: Developmental

Christophe Gaudet-Blavignac^1,2, Andrea Rudaz³, Christian Lovis^1,2

¹Division of Medical Information Sciences, Geneva University Hospitals, Geneva, Switzerland.

JMIR Medical Informatics

|August 9, 2022

Summary

This study corrects a previously published article DOI. The correction ensures accurate citation and retrieval of research findings for better scientific communication.

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Area of Science:

Bibliometrics
Scientific Publishing

Context:

Correction of a published article DOI is essential for maintaining the integrity of scientific records.
Accurate digital object identifiers (DOIs) facilitate efficient retrieval and citation of research.

Purpose:

To provide the correct DOI for a scientific publication.
To ensure researchers can accurately access and cite the intended article.

Summary:

The article DOI has been corrected to 10.2196/29174.
This correction rectifies a previous error in the digital object identifier.

Impact:

Ensures accurate referencing and citation of the scientific work.
Improves the discoverability and accessibility of the research through correct DOI linkage.