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Problem Oriented Medical Record (POMR) & Soap Notes
Ryan Emery
Created on January 9, 2023
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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):
Disposition
Database
Initial Plan
Encounter Progress Note
Problem List
Click the following button to learn what SOAP stands for:
SOAP Note Format
Encounter notes are structured using the SOAP note format.
Subjective
Objective
Assessment
This includes the patient’s chief complaint and the history of present illness, emphasizing elements that contribute to the differential diagnosis.
Plan
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.).
This summarizes the working diagnosis, rationale, and other possibilities that need to be addressed. The assessment should guide the plan.
The plan includes further diagnostic investigations, therapeutic interventions such as medications or interventions, and appropriate counseling and patient education.
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