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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 III: PIE

Methods of Documentation III: PIE

Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:

Interdisciplinary Care: The Health Care Team-I

Interdisciplinary Care: The Health Care Team-I

An interdisciplinary team includes many healthcare professionals working together and utilizing their skills, knowledge, and expertise to provide holistic and quality patient care.
Physicians
The physician's primary responsibility is to diagnose illness and direct the medical or surgical treatment of the condition. The authority to admit patients to a healthcare agency or institution and practice care within that setting is granted to physicians by the healthcare agency or institution...

Obedience

Obedience

According to obedience research, we may harm others under the forceful pressures of an authority figure (Milgram, 1974). How about if the inappropriate orders were delivered with less force? The increasing interdependence between nurses and physicians compelled Hofling and his colleagues to explore nurses’ reactions to a potentially harmful medical request made by the perceived authority figure, the doctor (Hofling, Brotzman, Dalrymple, Graves, & Pierce, 1966). In this situation,...

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:

Methods of Documentation VI: Case Management Model

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...

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Related Experiment Video

Updated: May 15, 2025

A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography

A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography

Published on: July 22, 2022

Physicians' prism: illuminating history with structured expertise.

¹Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, Japan.

Diagnosis (Berlin, Germany)

|April 10, 2025

Summary

The GREAT PRISM strategy enhances patient history reconstruction for accurate diagnosis. This framework uses Grid analysis to organize information, improving diagnostic precision at the point-of-care.

Keywords:

clinical reasoning diagnostic error diagnostic excellence improving diagnosis medical history

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Last Updated: May 15, 2025

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Area of Science:

Medical Informatics
Diagnostic Medicine
Clinical Decision Support

Background:

Accurate patient history is vital for effective diagnosis and treatment.
Current methods often face challenges in comprehensive history reconstruction.
Gaps in patient history can lead to diagnostic errors and suboptimal outcomes.

Purpose of the Study:

Introduce the GREAT PRISM strategy to overcome barriers in patient history reconstruction.
Enhance the resolution of patient history for improved diagnostic accuracy.
Bridge traditional practices with modern diagnostic approaches.

Main Methods:

Utilizing Grid analysis to organize patient information.
Mapping patient data along temporal and symptomatic axes.
Employing techniques like identifying missing information and uncovering hidden histories.

Main Results:

Achieved high-resolution patient narratives through structured data organization.
Demonstrated the effectiveness of temporal pattern dissection.
Facilitated precision in diagnostic excellence.

Conclusions:

The GREAT PRISM strategy offers a robust framework for comprehensive patient history.
Grid analysis provides a structured approach to diagnostic data.
This method supports point-of-care diagnostic excellence through enhanced historical data.