The Problem Oriented Medical Record
As late as forty years ago, physicians kept their office records on hand written progress notes and histories stored in file folders, some letter size and some on 5x8 file cards. Hospital records consisted mostly of files stuffed with hand written notes and little lab reports stapled to a sheet of paper.
The information was provided to assist anyone involved in the care of the patient to make informed judgments and provide continuity of care.
In the early 1970’s a New Hampshire physician, Lawrence L. Reed, wrote a monograph entitled Medical Records, Medical Education, and Patient Care; “The Problem Oriented Medical Record”. It was intended that a modern medical record provide a unified approach that would make for consistency and ready dissemination of information in a standardized form. This also was seen as a means to provide a form that would adapt more easily to the emerging information technologies.
The Problem Oriented Medical Record (POMR) has become an absolute standard today and governs the entry protocols in Medical Records departments not only in this country, but world-wide. The traditional records of Family History, Past Medical History and Socio/Economic History remained pretty much the same (with however, increased emphasis on socio/economic factors). The major difference was in the organization of the various factors of a medical encounter. They are four in number:
The SOAP Record
[S] Subjective factors – (related mostly from the patient and immediate participants)
[O] Objective findings – Physical Signs and Laboratory Confirmations
[A] Assessment – (considerations of diagnostic possibilities)
[P] Plan – (the next steps in diagnosis and therapy)
The POMR is an ever-present factor in your care whether it is at home, the office or the hospital; of course it will also be a standard part of any entries into your own Electronic Medical Record (EMR) especially if you are being seen in a Managed Care environment.
One of the goals of this website is to encourage you to compile and maintain a record of significant medical encounters. It is our philosophy that the history of all of the significant events in your life should be under your control and yours only... not your life insurance company, your bank, a national credit reporting service or even your doctor or hospital. Those entities will have a fragmentary view of your health but ultimately the intimate details of your life and health should be yours and yours alone to be shared with others only as you see fit.
Whether you maintain your health history in a hand-written journal, a set of files in a file cabinet, or for the computer buffs, a spread sheet, word processor or complex database, we hope you will find the accompanying aids helpful.