What is a major difference between a problem oriented medical record and a source oriented medical record?
- A- The problem oriented medical system has a centralized part of the chart for interdisciplinary progress notes and the source oriented medical record has separate areas for each profession’s progress notes.
- B- The problem oriented medical system consists of narrative progress notes and the source oriented medical record uses SOAP.
- C- The source oriented medical system uses charting by exception and the source oriented medical record system does not.
- D- The source oriented medical system has a centralized part of the chart for interdisciplinary progress notes and the problem oriented medical record has separate areas for each profession’s progress notes.
Correct Response: A
The problem oriented medical system has a centralized part of the chart for interdisciplinary SOAP progress notes and the source oriented medical record has separate areas for each profession’s progress notes. Although source oriented medical records can use SOAP, this is not a defining characteristic and most of these notes are free formed narrative notes. Charting by exception is a distinctly different medical system than source or problem oriented medical systems.The major difference between a problem-oriented medical record (POMR) and a source-oriented medical record (SOMR) is the way that information is organized. In a POMR, information is organized around the patient's problems. In a SOMR, information is organized by the source of the information, such as the doctor, nurse, or laboratory.
Problem-oriented medical record (POMR):
A POMR is a medical record that is organized around the patient's problems. It consists of four sections:
- Problem list: A list of all of the patient's current and past problems.
- Data base: A collection of all of the information about the patient's problems, including the patient's history, physical examination findings, and diagnostic test results.
- Assessment: A summary of the patient's problems and the physician's assessment of the patient's condition.
- Plan: A plan for managing the patient's problems.
Source-oriented medical record (SOMR):
A SOMR is a medical record that is organized by the source of the information. It typically consists of the following sections:
- Chief complaint: The patient's main reason for the visit.
- History of present illness: A detailed description of the patient's symptoms and problems, including the onset, duration, and severity of the symptoms.
- Past medical history: A list of the patient's past medical problems, surgeries, and allergies.
- Review of systems: A review of the patient's body systems to identify any other potential problems.
- Physical examination: A detailed physical examination of the patient.
- Laboratory and imaging results: A summary of the results of any laboratory tests or imaging studies that were performed.
- Assessment and plan: The physician's assessment of the patient's condition and a plan for managing the patient's problems.
Advantages of POMR:
The POMR format has a number of advantages over the SOMR format, including:
- It is easier to find information about specific problems.
- It is easier to track the patient's progress over time.
- It is easier to communicate with other healthcare providers about the patient's care.
- It is easier to use for quality assurance and research.
Disadvantages of POMR:
The POMR format also has some disadvantages, including:
- It can be more time-consuming to write and maintain a POMR.
- It can be difficult to use POMR software effectively.
- Some physicians may be reluctant to change their practice to use POMR.
Advantages of SOMR:
The SOMR format has a number of advantages over the POMR format, including:
- It is easier to write and maintain a SOMR.
- It is more familiar to many physicians.
- It is easier to use for certain types of patients, such as patients with multiple problems or complex medical conditions.
Disadvantages of SOMR:
The SOMR format also has some disadvantages, including:
- It can be difficult to find information about specific problems.
- It can be difficult to track the patient's progress over time.
- It can be difficult to communicate with other healthcare providers about the patient's care.
- It can be difficult to use for quality assurance and research.
Conclusion:
The POMR format and the SOMR format are both valid ways to organize medical records. The best format for a particular practice will depend on the specific needs of the practice and the preferences of the physicians.
