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POMR + SOAP
PGYChart Round
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-1
()
(Note)
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-2
(accurate)
(complete)
(comprehensive)
(consistent)
(integrated)
(legible)
(timely)
(legal)
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CHART
2008 CHART
CHART
Clear
Honest
Accurate
Readable
Timely
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()
67
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()
12
-
88.12.22.88069470
..
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1025.1
1.2.
(1)
(2)admission note
(3)progress note
(4)weekly summary
(5)operation record(6)off service note, transfer note
(7)discharge summary
3.physical examination
4.
[] not applicable, NA
5.1.5
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1025.3
1.
2.
(1)
(2)
(3)
3.(physical examination))system review)(positive
findings)(negative findings)
4.
5.
[]
not applicable, NA
5.3.5
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Problem-Oriented Medical Record (problem-list) admission
Progress note POMR + SOAP weekly summary,
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What are 3 common formats used to document patientprovider
encounters
Narrative
POMR
SOAP
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Narrative Format
,,
Oldest format
Least structured format
Paragraphs indicate: Contact with patient
What was done
Outcome
Weekly/Discharge summary, On/Off-Service Note, Transfer Note,
etc
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POMR Format
POMR = problem-oriented medical record
Patients problems listed with numerical references
Beneficial in group practices
Easy to track treatment and progress
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S O A P Format
Subjective data () What patient says
Use quotations () where possible
Objective data () What is observed during assessment and
examination
Assessment ((+)SO) Patients diagnosis, prognosis, response to
management
Plan () List of interventions (diagnostic, educational,
therapeutic)
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Problem Oriented Medical Record (POMR)
Lawrance Weed (1964)
(problem)
progress note
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(Problem-oriented medical record, POMR)
(data base)
(problem list)
(progress notes SOAP )
[ P.O.M.R.
S.O.A.P.
]
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POMR
()
SOAP
Active probleminactive
resolved
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POMR
Data baseHistoryPhysical examinationsLaboratory data
Problem list#1 ....#2 ....#3 .............
Progress note#1....S:O:A:P:
Initial plan#1Diagnostic planTherapeutic planEducational
plan
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:
medicalsocial
psychiatric
:
active problem)
inactive problem
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POMR
POMRproblem
POMR progress note
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POMR
1.
2.
3.
4.
S/O
5.
-
Assessment =
Stable
Making improvement
Making good recovery
Deteriorating
Not going to make it!
Fever settled
Appetite improved
WBC back to normal
Pain much relieved by
Dyspnea lessened by
Making good recovery from
Increasingly severe dyspnea
Worsening lumbago
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Assessment
Admission note Impression
:
Sepsis R/O Pneumonia
Type 2 Diabetes Mellitus
Hypertension
History of cervical cancer, S/P total hysterectomy, 8 years
Diarrhea, cause to be determined
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Assessment
Sepsis, possible due to Pneumonia, RLL; Pneumonia confirmed
by
chest X-rays. 5rd day of cefuroxime 1.5 g IV q8h. WBC
decreased.
Clearly improving with less cough and no fever .
Type 2 Diabetes Mellitus: Sugar level (Ac:105 with F/S ) is
under
control with glipizide 1#Qd
Diarrhea, stopped 3 days after admission. Stool culture was
negative.
Cause is possible related to the pneumonia? Legionella?
Hypertension: on Enalpril (20mg) 1#Qd and Behyde 1#Qd, BP
180/96
mmHg, poor control still .
History of cervical CA: Checked by Gynecologist. No signs of
recurrence.
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( Plan, P)
(Diagnostic Plans):
(Therapeutic Plans): (O2 ? L/min)
hemodialysisAntibiotics []
(Educational & Informed Plans):
(Consultation Plans):
(Follow-up Plans):
-
?
active
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The problems of POMR + SOAP
1. paper work
2. SO
3. SO
4. problemSO (hypokalemia)
5.
6.
7.
8.
9.
10.
Feinstein AR, Annals Internal Medocine, 1973;751-62
Bossen C, International Journal of Medical Informatics,
2007;592-600Bates B. Physical examination and history taking 6th
edition JB Lippincott
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POMR
POMR
-
Modified POMR
Data baseHistoryPhysical examinationsLaboratory data
Problem list#1 ....#2 ....#3 .............
Progress noteS:O:A/P:
# 1: A: P:
#2: A:P:
Initial assessment and plan#1 Assessment
Plan #2 Assessment
Plan
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?
& & & &
: : : : (((())))
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Chart Round
12
676869
()
()
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Chart Round
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Chart Round
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Chart Round
207 208
PGY
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Chart Round
()
Admission/Progress/Discharge Note
round
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(http://www.tjcha.org.tw/)
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