Question

identify methods of organizing medical records based on a. problem-oriented medical record POMR and sourse-orientted medical record SOMR

Answer 1

Methods of organizing medical records based on a Problem-oriented medical record (POMR) and source-oriented medical record (SOMR)

• Problem-oriented medical record (POMR)

The problem-oriented medical record collect data or information from all members of the patients care team in order to decide a diagnosis and creating a treatment plan.The correct use of problem-oriented medical record of the does just the reverse and results in concise, complete and percise or accurate record keeping and it is a comprehensive approach to recording and obtain patient data.

Four components of POMR:

1. A database of complete history and physical exam.
2. Compelete problem list(  list of the after the admitting physician performs the history)
3. A treatment plan for each problem (intial plans)
4. Discharge summary( comprise active plan and final progress note should be the undetermined problem)

• Source-Oriented Medical Record (SOMR)

The source-oriented medical record is more convential format used for recording data in the medical record. SOMR is the chart with organized source of patient's medical record.A kind of patient chart record keeping that includes discrete sections for different sources of patient detials, such as laboratory reports, pathology reports, and progress notes.