Pric And Prac Unit 1

Front 1

Problem Oriented Medical Record (POMR)

Back 1

The Database
The Problem List
The Plan
The Progress Notes

Front 2

Database

Back 2

Routine information about the patient
General health history
Physical exam
Results of diagnostic tests

Front 3

Problem List

Back 3

Problem – interferes with patient’s health or ability to function
Based on information from the database
Dynamic – new problems are added as they occur, and others are removed as they are resolved

Front 4

Progress Notes

Back 4

Findings, assessments, plans, orders and notes of members of the health care team
Separate notes are written for each problem in the list
S.O.A.P. format used
Subjective
Objective
Assessment
Plan

Front 5

Subjective

Back 5

Subjective – Information obtained from the patient or relatives. What the patient tells the health care provider - interview
Dyspnea
Pain
Hot/cold
Fear

Front 6

Objective

Back 6

Objective – Directly measured information or data obtained by the health care provider –
Physical exam
Lab tests
Vital signs
x-ray

Front 7

Assessment and Plan

Back 7

Assessment: Analysis of the problem based on the subjective and objective findings

Plan: Identifies the actions or interventions to resolve the problem

Front 8

Entering Information in the Chart

Back 8

Each entry should be signed with first initial, last name and title. Student entries may need to be co-signed
Do not use ditto marks
Do not erase. If a mistake is made, draw a single line through the mistake, write “error” above it, then continue charting
Record after completing each task, and sign name after each entry
Never chart for someone else.

Front 9

Entering Information in the Chart

Back 9

Be exact in noting time, effect and results of all treatments or procedures.
Chart patient complaints and general behavior. Describe the type, location, onset dn duration of any pain. Describe the character and amount of secretions.
Leave not blank lines in the charting. Draw a line through the center of an empty line or part of the line so no one else can enter information in area sighed by you.

Front 10

Entering Information in the Chart

Back 10

Use standard abbreviations
Use the present tense (not future tense) as in “Patient to receive treatment after lunch”
Spell correctly
Document conversations with the patient or other health care providers about information important to the patient’s care.