Taking the problem oriented medical record forward

Area of Science:

• Medical Informatics
• Health Information Systems
• Clinical Documentation

Background:

• The problem-oriented medical record (POMR) is a validated structure for clinical notes.
• Increased computerization highlights POMR limitations in data quality and meaning.
• There is a need for further development of the POMR model.

Purpose of the Study:

• To identify limitations of the current problem-oriented medical record (POMR) system.
• To propose and discuss implementable extensions for the POMR.
• To enhance the quality and meaning of recorded patient data.

Main Methods:

• Analysis of existing problem-oriented medical record (POMR) structures.
• Exploration of extensions including encounters, episodes, subproblems, and a Timeline view.
• Description of implementation mechanisms and automatic management strategies.

Main Results:

• Identified limitations in the current problem-oriented medical record (POMR) structure.
• Proposed and clarified terminology for extensions such as encounters and timelines.
• Described practical implementation and management of these extensions within clinical systems.

Conclusions:

• The problem-oriented medical record (POMR) can be extended to improve data quality and usability.
• Extensions like encounters and timelines offer enhanced patient history views.
• Implementations must balance system demands with clinical workflow and reporting requirements.