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Somr and Pomr

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165 views16 pages

Somr and Pomr

Uploaded by

Krishna Kanth
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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SOMR , POMR

By - Rajeev Naik

Roll No. - 43

Batch - 2018

Moderator :-Dr Smita Sinha

Department of Community and Family Medicine,

AIIMS Rishikesh
SOURCE ORIENTED MEDICAL RECORD (SOMR)

● Most traditional format used for recording data in the medical


record.
● SOMR are organized by subject matter or discipline.
.

● Subject matters or discipline examples: lab reports, progress notes for


OT, Progress notes for nursing, etc.
● Progressive notes are usually recorded in narrative format.
.

● All reports and notes are kept in Chronological Order,


meaning the most recent note on top.
● Easy to find Specific information.
.

● There is no systemic cross-referencing of data from one section to


the next.
● Problems and Treatments are on same form.

● Easy and fast to record, omitting information is highly possible.


● Advantages:
○ Information is in Chronological Order.

○ Documents patient’s baseline condition for each shift.

● Disadvantages:

○ Documents all findings: makes it difficult to separate pertinent


form irrelevant information.
PROBLEM ORIENTED MEDICAL RECORD
(POMR)
○ It was developed by Lawrence L.weed in the early 1970s.

○ POMR system incorporates structure and Organization within


medical chart.

○ It is systematic and data is easily accessible.


.

COMPONENTS OF POMR:
● Data Base

● Complete problem list

● Initial plans

● Daily progress note

● Final Progress note or Discharge summary.


SOAP NOTES:

● The pomr system uses the Subjective, objective, assessment, plan


(SOAP) note format for each progressive note.
● SUBJECTIVE IMPRESSIONS (S):

○ Information provided by the patient.

● OBJECTIVE IMPRESSIONS (O):

○ Information provided by the health care professional includes a list of


measurable reproducible data.
.

● ASSESSMENT (A):
○ Interpretation of subjective and objectives findings.

● PLAN (P):

○ Provider’s plan for diagnosing and treating the patient.


.

Advantages:
○ It makes exploration of charts much more efficient.

○ It decreases ambiguity of prior problems and treatment goals.

○ It encourages uniformity amongst those using chart.


Disadvantages:

○ Results in loss of Chronological Order.

○ More difficult to track trends in patient status.

○ Fragments data because more flow sheets required.


Q1) Which format has no systemic cross-referencing of
information?
A) POMR
B) Organizational
C) SOAP
D) SOMR
Q2) In the POMR format, the category that includes patient history,
physical findings, and baseline results is the:

A) Problem list
B) Data Base
C) Plan
D) Progress note
References
● http://medical-Dictionary.thefreedictionary.com/problem-oriented+medical+r
ecord.
● http://thehealthcareblog.com/blog/2013/05/10/the-problem-oriented-medical-
record/.

● Kettenbach G.Writing SOAP Notes, 2nd Ed. Philadelphia PA: F.A.Davis


company,1995.
http://drive.google.com/file/d0B-tlCbPSHvfZamVyMjl0SFBvVDA/view?usp
=sharing.
Thank You.

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