Fillers A book that changed my practice

Problem oriented medical records

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7281.275 (Published 03 February 2001) Cite this as: BMJ 2001;322:275
  1. Peter Savage, consulting surgeon
  1. Sidcup

    As part of my senior registrar training at St Mary's in the late 1960s I spent a year working on the cardiothoracic unit. It was while wrestling, both physically and mentally, with the two, three, or even four volumes of case notes of patients coming for cardiac surgery that I thought that there must be a better way of organising them.

    Help was at hand. A film of one of Lawrence Weed's presentations was shown in the medical school. His vivid demonstration of what he thought of disorganised and confusing case notes caught my imagination. Why could doctors not use a scientific methodology when recording their clinical findings? I was seized with a missionary fervour and for 35 years used the principles of the problem oriented medical record (POMR) in my clinical and teaching practice.1

    Weed pointed out that the features with which patients present could, by the application of an inquiring and trained mind, be designated as problems. These might be a symptom, a sign, an abnormal laboratory or radiological finding, a social burden or a previously diagnosed disorder. “Active” problems needed evaluation while all carers needed to be aware of the “inactive/resolved” ones. To identify all the problems history taking, physical examination, and investigations had to be defined and complete.

    The type of clinical practice involved in the patient's care defines this database. S ubjective data (S) is compiled from the history, objective data (O) from the physical examination and the results of any investigations. The assessment (A) explains the identified problem in pathophysiological terms and the evaluation of each active problem concludes with a management plan (P) of investigations (Dx) to confirm or rule out a condition, treatment (Rx), and education (E). By placing the problem list at the front of the clinical record everyone involved in patient care can be aware of the list of active and inactive/resolved problems. Where appropriate the results of investigations and changes in clinical status are displayed on data summary sheets and flow sheets. Those responsible for changing a management plan use the mnemonic SOAPto record their findings and reasons for so doing. Discharge summaries and letters to colleagues use the same format.

    I found Weed's principles useful in teaching medical students the basics of clinical deduction, invaluable for demonstrating the importance of their clinical notes to pre-registration house officers, and an essential part of SHO and registrar training. My attempts to introduce POMR throughout my hospital were less successful. In later years as an assessor advising on clinical complaints, how I wished more doctors had heeded Weed's advice.

    Did POMR improve patient care on my unit? I think it did and it was encouraging to see that the American Institute of Medicine thought so too.2 Have any of my trainees continued to use POMR in their clinical practice? I don't know—perhaps I ought to find out now that I have all this spare time.

    2 Institute of Medicine. The computer-based patient record: an essential technology for health care. Washington DC: National Academy Press, 1991.

    Footnotes

    • 1 Weed LL. Medical records, medical education, and patient care. The problem-oriented record as a basic tool. Cleveland, OH: Case Western Reserve University, 1969.

    • We welcome articles of up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.

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