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Taking the problem oriented medical record forward

P Salmon1, A Rappaport, M Bainbridge

  • 1Primary Health Care Specialist Group, British Computer Society.

Proceedings : a Conference of the American Medical Informatics Association. AMIA Fall Symposium
|January 1, 1996
PubMed
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The problem-oriented medical record (POMR) can be enhanced to improve patient data quality. This study explores extensions like encounters and timelines for better medical record systems.

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.

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  • 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.