Problem Oriented Medical Record

Original Editor - Gayatri Jadav Upadhyay

Top Contributors - Ajay Upadhyay, Pooja Shevale, Gayatri Jadav Upadhyay, WikiSysop and Kim Jackson


Introduction:[edit | edit source]

Problem Oriented Medical Record (POMR) is a medical record approach that provides a quick and structured acquisition of the patient’s history.[1] It was born in the late sixties. Expecting an ordered, complete and updated medical record were some of the goals.[2] POMR, unlike classical health records, focuses on patient’s problems, their evolution, and the relations between the clinical events. This approach provides the physician a view of the patients’ history as an orderly process to solve their problems, giving the opportunity to make explicit hypotheses and clinical decisions. Most efforts regarding POMR focus on the implementation of information systems as an alternative of classical health records. Results reveal that POMR information systems provide a better organisation of patients’ information but unsuitable mechanisms to perform other basic issues (e.g. administrative reports).[1]

Developer[edit | edit source]

Developed by Weed and Zimny [3]

Phases of POMR[edit | edit source]

Phase 1 The formation of a database, including history, physical examination and laboratory and other test results

Phase 2 Identification of a specific problem list from the interpretation of the database, including specific impairment of function (Physical, psychological, social and vocational) resulting from the disease process or from secondary impairments.

Phase 3 Identification of a specific POC that includes interventions for each of the problems described; evaluative and progress notes are included for each problem.

Phase 4 Determination of the effectiveness of the POC and subsequent changes as a result of patient progress.

It Highlights[edit | edit source]

The POMR thus highlights the relationship of the database to the POC and allows the specific patient problems to become the central focus of planning.

Advantages[edit | edit source]

Due to its features, POMR can help to bridge the gap between the traditional clinical information process and knowledge management.

Other Implications:[edit | edit source]

Despite the potential advantages of POMR, only few efforts have been done to exploit its capacities as a knowledge representation model and a further automatic reasoning. In this work, we propose the Problem Flow, a computational model based on the POMR. This proposal has a double objective: (1) to make explicit the knowledge included in the POMR for reasoning purposes and (2) to allow the coexistence between classical health records and the POMR.

References[edit | edit source]

  1. 1.0 1.1 Juarez, J.M., Campos, M., Gomariz, A., Morales, A. (2012). Computing Problem Oriented Medical Records. In: Riaño, D., ten Teije, A., Miksch, S. (eds) Knowledge Representation for Health-Care. KR4HC 2011. Lecture Notes in Computer Science(), vol 6924. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-27697-2_9
  2. Franco M, Giussi Bordoni MV, Otero C, Landoni MC, Benitez S, Borbolla D, Luna D. Problem Oriented Medical Record: Characterizing the Use of the Problem List at Hospital Italiano de Buenos Aires. Stud Health Technol Inform. 2015;216:877. PMID: 26262179.
  3. Bringing science to medicine: an interview with Larry Weed, inventor of the problem-oriented medical record.Wright A, Sittig DF, McGowan J, Ash JS, Weed LL.J Am Med Inform Assoc. 2014 Nov-Dec;21(6):964-8.