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Problem Oriented Medical Record (POMR) & Soap Notes
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Problem Oriented Medical Record (POMR) & Soap Notes

Electronic health records are structured using the Problem Oriented Medical Record (POMR) method of record keeping. While the names of these components vary, what they contain does not. POMR has five components (Click each component to learn more):

Database

Problem List

Initial Plan

Encounter Progress Note

Disposition

Click the following button to learn what SOAP stands for:

The database covers the patient’s history, physical exam, and labs/studies.

The problem list is an index of a patient’s medical problems. “Active” problems are medical conditions for which the patient is currently being treated. “Inactive” problems are medical conditions for which the patient was treated previously but have since resolved.

Each active problem in the problem list should have a plan. This plan is documented in the SOAP note (see below). On the inpatient side, you will need to write a plan for medical problems that are actively being treated. This includes the reason for their admission as well as ongoing problems that will be treated during the patient’s stay, such as hypertension and diabetes, even if they are not the primary reason for the admission. You do not need to write a plan for inactive problems.

These include daily progress notes in the hospital and visit notes in the outpatient setting. Encounter notes are structured using the SOAP note format. Click the button below to learn more about SOAP.

This outlines the care that has taken place and what the next steps are for the patient after they leave the visit. This is captured in a discharge summary for inpatients and instructions for follow up for outpatients.

SOAP Note Format

Encounter notes are structured using the SOAP note format.

Subjective

This includes the patient’s chief complaint and the history of present illness, emphasizing elements that contribute to the differential diagnosis.

Objective

This includes the pertinent objective data related to the patient’s presentation, including vital signs, a pertinent physical examination, and pertinent testing (lab, radiology, pathology, etc.).

Assessment

This summarizes the working diagnosis, rationale, and other possibilities that need to be addressed. The assessment should guide the plan.

Plan

The plan includes further diagnostic investigations, therapeutic interventions such as medications or interventions, and appropriate counseling and patient education.

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