THE PROBLEM ORIENTED MEDICAL RECORD (POMR)

MEDICAL PROBLEM SOLVING: AN OVERVIEW

The information and observations gathered from the history and physical examination
become the evidence used by physicians to form hypotheses (diagnoses).

The hypotheses are generated from the beginning of the interview and are changed or
rearranged as the interaction progresses. The hypotheses seek to rationally and
scientifically explain all of the abnormalities found in the database. Eventually, all of
the abnormalities are identified, prioritized, and organized into a Problem List. The
Problem List provides the outline of the patient's medical history.

The Problem List allows us to group related complaints and physical findings pertinent
to each hypotheses (tentative diagnoses) and develop plans for further diagnostic
evaluation, treatment, and patient education.

Problem-Oriented Medical Records

There are four components to the POMR:
A. The Defined Data Base
B. The Complete Problem List
C. The Initial Plans
D. The Progress Notes

There are many advantages to the POMR but it has been adopted primarily because it
serves as a format for recording the diagnostic reasoning of the physician and it includes
a plan for evaluating and managing each problem. In addition, the record is easily
audited for evaluation of the quality of patient-care rendered by the physician.

The patient's recorded history represents the ORGANIZATION and

INTERPRETATION of material derived from the interview (as well as from other
sources, such as previous medical records or outside informants). The preparation of
the written history is more complex than recording the findings of the physical
examination. It involves making certain judgments as to what differentiates the current
illness from illness in the past. It calls for decisions as to the relevance of data and their
proper assignment to the major categories Present Illness (PI), Past History (PH);
Family History (FH), System Review (SR or ROS), Patient Profile (PP). To write a
well-organized history, it is wise first to review in one's mind the information obtained
from the interview. The data must be examined particularly for completeness; and it
may be necessary to go back to the patient for clarification or exploration of issues that
were not fully appreciated during the initial interview.

Thought must be given to clarity and conciseness of language in the final draft. One
must learn to be accurate and complete, yet sufficiently to the point so that the physician
who reviews the chart can do so without being misled by ambiguities, omissions,
distortions or misstatements. Events are reported in the sequences in which they
occurred and symptoms are delineated in terms of their seven dimensions.

Throughout the written history careful distinction must be made between

DESCRIPTION of data and its INTERPRETATION. It is improper, for example, to
write: "The patient is having angina pectoris", rather it is best to record a complete
description of the symptoms in question, allowing the reader to form his/her own
opinion.

Quotations are used sparingly and only when the patient's exact words contain specific
information. Quotes are also used when recording an undocumented medical term used
by the patient, such as "nephritis" or "nervous breakdown", but these should always be
followed by a brief description of the condition so named. It is unnecessary to write
"The patient said..." This adds to the length of the history and decreases readability.

Emphasis should be on the description of symptoms and events as these affect the
patient, rather than on the physician’s report of what the patient said or did.

Finally, as the physician writes a history, he/she should constantly keep in mind the
future reader and anticipate questions arising in the reader's mind and include pertinent,
positive and negative information.
Audit
The thorough recording of the database leads to a third component of the problem-
oriented system: quality control. This will help both the students and faculty to interpret
the 4 following items that are used to judge the quality of the student's work:
Thoroughness: Is the database complete?
Reliability: Is the data accurate? The recording of the examination of the liver provides
an opportunity to go back and recheck the accuracy of the perception. Does the
physician follow through on his/her plans?
Efficiency: Is data collected and problem-solved in a reasonable length of time?
Analytical sense: The logic pathways used in solving problems are clearly outlined in
this system and are amenable to evaluation by peers or teachers.
The standard for measuring the overall process is the standard expected of medical
students at their level of training. Our objective is to prepare you adequately to proceed
to the next step in your medical education.
Education Programs
This problem-oriented medical record system makes it possible to link observation,
record-keeping, formulation or assessment, and hypotheses testing to the daily activities
of medical practice. Using this system we can identify deficiencies in the student's
ability to observe, record, formulate and test hypotheses in such a way that these
deficiencies can be corrected. The problem-oriented system provides the sequence of
events and feedback loops required to learn medicine and to deliver excellent patient
care.

In summary, the principles of practice of medical students have been established

through defining their specific goals at each stage of their medical education. The
problem-oriented system will need re-defining particularly as the student advances into
the clinical years and as he/she enters postgraduate education. The use of the problem-
oriented record is required for the student and outlines the defined database, the
problem list, the initial plans, and the progress notes formats to be used in patient
evaluations. Audit will be through comparing the database, whether presented orally or
from the written form, with what is expected of students and will concern itself with
thoroughness, reliability, efficiency, and analytical sense. This system will be used to
learn medicine and to deliver excellent patient care by teaching and reinforcing those
behaviors that are appropriate to that end.
DETAILS OF THE PROBLEM ORIENTED MEDICAL RECORD (POMR)
1. THE DEFINED DATA BASE
This is the general body of information collected on most patients. The Database
consists of the patient’s identifying data, the chief complaint, a statement about data
sources and reliability, the Present Illness, Past Illness, Family History, Patient Profile,
Review of Systems, and Physical Examination.

2. THE PROBLEM LIST

The Problem List should be the first page of the medical record. It is derived from the
information in the Data Base (e.g., the history and physical examination). It is the index
or table of contents of the record. A problem is defined as anything that requires further
diagnostic workup; requires medical or other therapeutic management; interferes with
the quality of the patient's life as perceived by the patient; or in the opinion of the
physician may be potentially a matter interfering with the quality of the patient's life.
The problem should be stated at the level of understanding that can be defended by the
data which are available. The problem list should show the date the problem was
entered (the date when the physician identified the problem), the date the problem
started, and the date when the problem was resolved. Each problem should be
numbered. The problem number and title will be used throughout the record when
initial plans and subsequent progress notes are written. Problems requiring further
resolution should have an arrow placed after them. The date the problem was resolved
should be placed above the arrow. The date is a pointer to the progress note which
displays the evidence and logic used to change the problem from one that is of a low
level of resolution to one that is of a high level of resolution. The problem list should
be continually updated. There must be no delay in adding a newly discovered problem
to the list or indicating how a problem has changed from a "low level resolution" to a
high level resolution". When for any reason the defined data base cannot be obtained,
or portions of it are missing, this should be formulated as a problem on the problem list.
Such a problem should be identified as " Problem #1... incomplete data base."

3. INITIAL PLANS: PROBLEM ASSESSMENT AND PLANS

a) Problem Assessment:
For each numbered and titled problem an Assessment will be composed, which will
include differential diagnosis (choose between competing hypotheses) to explain the
issues posed by the problem. The Assessment will include an analysis of the evidence
for and against each possibility, and should end with a statement of the rationale for the
next section, the Plans, based on probabilities and priorities of the particular patient's
situation.
b) Plan
Each problem assessment is followed by a statement of the initial plans covering 3
specific categories for that Problem:
1. The Diagnostic Plans outline the specific tests or procedures necessary to elucidate
that specific problem that are not already available in the defined data base.
2. The Therapeutic Plans define the specific drugs, dosages, and therapeutic procedures
to be undertaken.
3. The Patient Education Plans define what the patient and the family have been told
about the problem and the plans for further education

4. PROGRESS NOTES
Each narrative progress note should be numbered and titled to match the problem. The
progress note has 4 elements:
Subjective - from the historical data, symptoms
Objective - data from physical and laboratory examinations
Assessment - interpretation of the new subjective and objective data
Plan - new plans are based upon the assessment of new data
The physician considers the need for further diagnostic work, new therapeutic plans
and additional education of the patient and family. All information entered in the
problem-oriented medical record should be related to a specific problem which should
be numbered and titled to match the problem list. This includes:
The physician's orders
Consultation notes
Nurse's notes
Physical therapy notes
Dietitian's notes, etc.
THE FORMAT OF THE PROBLEM ORIENTED MEDICAL RECORD
PROBLEM LIST FORMAT
Date:_____________________
PROBLEM LIST
Name:_____________________________

Problem Date Active Date INACTIVE/RESOLVED

No. Onset Problems Resolved Problems
Date
Entered
1.
2.
3.
4.

FORMAT OF THE POMR MEDICAL NOTE

IDENTIFYING DATA (ID)
Name, age, sex, race, marital status and occupation (if retired - "retired plumber" or
whatever).

SOURCE AND RELIABILITY OF THE HISTORY (S/R)

Usually from the patient and statement such as "reliable historian".

REASON FOR EXAMINATION (RE)

Record the special reason for the examination at this time, other than the Chief
Complaint.
Examples:
"Pre-employment physical examination"
"Annual checkup"
"Referred by Dr. Heart for evaluation of cardiac murmur"
"Admitted to Coronary Care Unit from Emergency Room for probable myocardial
infarction"
Rarely, none other than the chief complaint will seem appropriate. If so, record:
"Medical attention for chief complaint" (see below).

CHIEF COMPLAINT (CC)

Record the one symptom IN THE PATIENT'S OWN WORDS and the duration. This
should be brief (1-3 words) and avoid detailed qualifications. Thus, "chest pain" rather
than "severe sudden onset sharp parasternal chest pain". If the CC occurred previously
and is no longer present, record as: CC: Abdominal pain. DURATION: For 2 days, 1
week ago.

PRESENT ILLNESS (PI)

The Present Illness refers to the recent change in health that caused the patient to seek
medical attention. It is an orderly and usually chronological account from the onset to
the "zero time" of the present examination that includes all the completely characterized
symptoms, signs, feeling, events and relationships that are pertinent to the patient's
current illness.

As a student, you will be interviewing people who may have been hospitalized for some
time. In this case the Present Illness should be the illness PRIOR TO
HOSPITALIZATION. The PI may then be followed by a sub-section titled:
"HOSPITAL COURSE, to give the events after admission to the hospital.

In general, the identification of the present illness begins with the symptoms and events
that cause the patient to seek medical attention. One must appreciate that the term,
present illness, does not necessarily refer to a single illness but TO ALL THE DISEASE
PROCESSES CONTRIBUTING TO THE PATIENT'S CLINICAL CONDITION AT
THE TIME OF THE EXAMINATION.

CHRONOLOGICAL ORGANIZATION
Each segment or paragraph of the PI is organized chronologically and related to the
"zero time" of or examination. One should avoid the nonspecific "Saturday before
admission" since this time interval will be unclear in the future.
Underlining the date or time at the beginning of each paragraph serves to highlight it
as:
"Four days prior to admission (September. 25, 1977), the patient first noted..."

ORGANIZATION OF THE WRITE-UP OF THE PRESENT ILLNESS

The PI can be organized as follows:
1. An initial orienting statement describing the patient's past health.
2. The general description of the PI.
3. A concluding paragraph that brings in any additional information pertinent to the
understanding of the problem.
Some physicians (as evidenced by the sample write-up) prefer to organize the PI as
follows:
1. Initial paragraph clarifying chief complaint and/or reason for examination.
2. A chronological description of PI.
3. A concluding paragraph of pertinent, positive and negative information.
Students should recognize that different formats will serve for different situations and
should be used appropriately.

INITIAL ORIENTING STATEMENT

Especially for patients with long standing medical problems, a brief statement
concerning the patient's health prior to the onset of the PI helps orient the reader to the
setting in which the PI occurred and sometimes indicates the reason for hospital
admission.
Examples are:
"Diabetes has been known for 5 years effectively controlled with diet and oral
hypoglycemic agents. The patient felt well until 4 days prior to admission, (Dec. 22,
1977) when she noted..."
"This patient has had poor health for 20 years with multiple hospital admissions with
at least 6 major surgical procedures (see PH). She was in her usual state of health until
3 days prior to admission, (Dec. 23, 1977) when..."
"The patient has been in excellent general health his entire life until 2 weeks prior to
admission (Jan. 2, 1977) when he first noted black stools."

Some of the items referred to in this initial statement are then written about in more
detail under Past Health. Those, in the judgment of the writer, which have direct bearing
on the patient's current situation, are described in more detail in the Present Illness.
THE GENERAL DESCRIPTION OF THE PRESENT ILLNESS
As already discussed, the description of the Present Illness is organized chronologically
by introducing the reader first to the symptoms and events leading to admission, then
going back to the apparent beginning of the illness, and tracing it up to the present.

The entire course of the Present Illness must be described, beginning with whatever is
taken as the point of onset of the current disorder. In addition to symptoms, this
description includes what the patient has done about the disorder, other medical
investigations or treatments, and anything which the writer considers contributory to an
understanding of the illness.

Reactions to specific circumstances in the illness should be incorporated into the body
of the Present Illness, including life situations bearing on the course of the illness--for
example, acute anxiety on discovering bright red blood in the stools; depression or
hypochondriacal concern upon feeling a lump in the breast; a fight with the boss
immediately preceding the onset of a symptom; or grief and mourning following a loss.

There is an almost endless variety of patterns to the present illness. These patterns may
be roughly categorized as:
1. AN ACUTE ILLNESS IN A PREVIOUSLY HEALTHY PERSON
When a patient has been in excellent health and develops an acute illness, the
organization of The Present Illness is relatively simple. One usually begins with the
initial symptoms and events and systematically describes the illness up to the time of
admission.

2. A RECURRING ILLNESS WITH ACUTE EPISODES

A patient may have a disease characterized by remissions and recurrences, often with
symptom-free intervals in-between. Examples might be bacterial pneumonia, a peptic
ulcer, or depression.

The fact that there has been previous episodes is mentioned in the initial orienting
statement. Next, a full description is given for the current episode.
In subsequent paragraphs, the previous episodes are described briefly with particular
emphasis on resemblances or differences from the current illness. Intervals between
acute episodes should not be neglected, since these may clarify what factors were
favorable for remission or what contributed to the recurrence. Mild symptoms
indicative of possible underlying disease should also be mentioned if they appear
relevant.

3. ACUTE MULTI-SYSTEM ILLNESS

Occasionally, a patient will have a complicated illness with symptoms involving several
systems. One must think carefully how to organize the Present Illness in the best way.
If the illness is relatively recent and symptoms are few, it may be wise to develop the
Present Illness chronologically, beginning with the earliest symptoms or events and
progressing to the time of hospital admission.

On the other hand, should there be multiple symptoms involving different organ
systems, all beginning at different times and evolving differently, it may be best to deal
with each major organ system in separate paragraphs. Such organization takes
experience and judgment since there may be more than one disease process and the
relationship between symptoms may be obscured by such arbitrary divisions.

4. NEW EVENTS RELATED TO A CHRONIC ILLNESS.

A patient may repeatedly have acute episodes in the course of a chronic illness. The
present problem should be fully described in the Present Illness followed by a summary
of relevant past events. In general, it is best to begin with an account of the most recent
episode or symptom complex.

One then goes back in time and attempts to identify the beginning of ill health and
develops a sequential story of the illness.

5. A NEW AND CLEARLY UNRELATED EVENT IN A CHRONIC ILLNESS.

If a patient with Parkinson's disease develops symptoms of ulcers, for example, it is not
necessary to include a description of Parkinson's disease in the Present Illness.
The reader is told of the chronic illness in the initial sentences and is referred to the Past
History for a fuller account.

If, on the other hand, the chronic illness plays a significant role in the
management of the unrelated new disease, a brief summary with pertinent
information concerning the chronic illness should be included at the end of the
Present Illness; and fuller details are included under the Past History.

6. DATA OF UNCERTAIN RELEVANCE

If there is information of uncertain relevance to the Present Illness, it is best
included in a separate paragraph rather than the Past History of System Review.

This may include psychological stresses and life events, such as a recent death or job
loss, where the chronologic relationship with the illness justifies
consideration.

THE CONCLUDING PARAGRAPH

The Present Illness concludes with a paragraph containing additional information
important to the full understanding of the patient's problem. It may include the
following items:
- Pertinent positive and negative information
- Medications and treatment
- Degree of disability

The divisions of the history following the Present Illness are organized to give a clear
picture of the patient's former health, the health of his/her family and his/her personal
development, relationships and achievements. The information is arranged in a way
that the reader can efficiently review pertinent data. Although complete sentences are
used for the PI and PP, an outline format is more effective for the PH, FH and SR.

The sample write-up and outline form should clearly indicate the organization of these
divisions of the history which have been elaborated upon previously.

THE PAST HISTORY

FAMILY HISTORY

THE PATIENT ("PERSON") PROFILE (“Social History”)

The purpose of the Patient Profile is to provide an overall perspective of the patient's
adjustment and functioning over the years. Accordingly, one inquires into his/her
performance and reactions under such circumstances as leaving school and home,
military service, marriage, illness or death of important persons, or changes in
his/herbeconomic or social status. As already stressed, emphasis is always on the
patient's reactions and methods of coping with these events, not simply on the event
itself.

This information is crucial to the appreciation of the psychological, social and cultural
aspects of his/her illness.
The physician attempts to paint a true picture of the patient as a person in recording this
profile. In order to do this, he/she must attempt to know the patient as a person.

An outline has been developed to assist students in obtaining and organizing the data
but the information is recorded in a narrative account.
One of the most difficult tasks is to provide enough information so that the personusing
your medical record can determine the overall background of the patient as well as the
current life situation.

As an interviewer, you will acquire a great deal of information which must be

summarized to prepare a well-organized, brief, pertinent report. You must omit many
details and provide only those items which seem most important in the full
understanding of this patient. The best approach is to outline your findings and then
make certain that you comment on every item. The amount of detail provided will
depend on the clinical situation.

THE REVIEW OF SYSTEMS

PHYSICAL EXAMINATION
PROBLEM LIST
Medical problem solving is the result of a series of complex interactions between
physician and patient from which are derived medically useful data. The initial standard
history and physical examination provide the clues which eventually permit the
identification of Problems.
Definition: Problem - Anything that requires diagnostic or management plans; or
interferes with the quality of life as perceived by a patient. Problems include specific
etiologic or anatomic, physiologic syndromes, symptoms, signs, laboratory
abnormalities, and behavioral aberrations, including social and psychiatric problems.
Each problem should be given a brief informative title at the most specific (i.e., highest)
level of diagnostic integration for which the physician judges the evidence convincing.
For medical problems, levels of diagnostic integration in order of decreasing specificity
are:
TYPES EXAMPLES
Etiology Pneumococcal pneumonia
Anatomy Cirrhosis, melanoma
Pathophysiology Congestive heart failure
Symptoms, signs Chest pain, clubbing
laboratory hyponatremia
behavioral drug abuse, unemployment, divorce

The problems should be listed in the order of importance selected as most significant
by the physician. Usually, the problem that is the cause of the chief complaint (the
iatrotropic symptom) should head the list.

This should be followed by active problems that may be related to the primary problem,
active unrelated problems, and past problems, inactive or resolved.

For each problem, there should be an Assessment and a Plan with diagnostic,
management, and Patient Education elements. Thus, the format of the analysis section
should be written on a problem-by-problem basis:
Problem #1: Rhinorrhea
Assessment
Plan
Diagnostic
Therapeutic
Patient education

The objective of identifying Problems is to eventually evolve Diagnoses, which are

problems at the highest stage of resolution. Problems evolve from non-specific
collections of signs and symptoms to highly refined diagnoses.

The Problem Oriented Medical Record uses the Problem List to record the Problems in
their order of importance as perceived by the physician and the patient. This list also
records the date of onset of the Problem and demonstrates the evolution of problem
solving in relation to that problem on the way to a diagnosis. Well organized Problem

Lists at the front of a patient's chart will provide a summary of this problem solving
process.

The permanent (or master) problem list is written on a separate page and is a table of
contents for the medical record. Each problem is given a number and title and a date
when the problem was formulated. The page is usually at the very beginning of the
medical record. When a new problem is added to the Problem List, it should be assigned
a new number and title.

Problems may be Active or Inactive, depending on whether they currently require

diagnostic or management plans. Inactive problems should be listed and identified as
inactive when they represent previous medical problems which often may bear on
current problems; they may also reactivate and become active problems.

As previously stated, problems may be abnormalities identified in the medical data base
which imply a great number of possible disease processes. The evaluation and ordering
of these clues in order to select one diagnosis from many possible diagnoses is called
differential diagnosis. Thus, the ability to eventually decide what a patient has in terms
of a disease process requires that the physician be able to identify abnormalities and be
able to relate them to disease entities where similar abnormalities are present. This
requires a knowledge base concerning diseases and heir related symptoms such as the
student acquires in studying pathology and in reading about medical-surgical illness.

A Tentative Problem List is the first distillation of abnormalities from a standard data
base. Questions that may be asked of each Tentative Problem are:
1. Is the "abnormality" really pathologic, or is it really a normal variant for that
person's age and sex?
2. Is that finding contributing to the patient's symptoms
3. Is that finding related to other signs and symptoms?
4. What organ system is involved?
5. What pathologic process can explain the sign or symptom or the collection of
signs and symptoms (e.g., a syndrome)?

A more refined Initial Problem List results from an evaluation of a general listing of all
abnormalities (the Tentative Problem List). As students become more expert in problem
solving, they will find that many clues may be considered together.

An initial Problem List, which will be a part of all required workups this year, will be
a series of headings or titles consisting of abnormalities found in the data base, dated,
and listed in order of importance and activity. Each problem is clearly stated and
defined on the basis of the information available at its highest state of resolution.
Related problems from the Tentative Problem List will be found in the Assessment, you
will subsequently write in reference to each problem, such that all abnormalities in the
data base are noted either as a title on the Problem List or in the assessment of a problem
to which they are related.

Eventually, all Problems become resolved as diagnoses. Diagnoses are names given to
disease processes based on criteria that evolve through studying many patients with
similar problems and outcomes. Problems usually begin as non-specific but highly
sensitive indicators of disease processes. From non-specific indicators, specific
findings associated with a disease permit one, on the basis of probabilities, to make a
diagnosis. A diagnosis is most highly resolved and most clinically useful when it can
be described Anatomically (Organ or organ system, morphologic changes),
Pathophysiologically (the biochemical or physiologic abnormality can be described),
Etiologically (the underlying cause), and Functionally (current state of limitation),
Therapeutically (state of function under present therapy), and Prognostically (likely
outcome with maximally effective therapy).

Non-specific but extremely sensitive clues to the presence of illness, which often are
included in tentative and initial problem lists are: dyspnea, chest pain, abdominal pain,
headache, edema, chronic diarrhea, ascites, splenomegaly, fever, polyuria, weight loss,
increased or decreased blood pressure, altered consciousness, disturbed menstrual
function, and short stature. Problem solving requires asking questions about these
abnormalities which are related to the way we understand, define, and categorize
disease. They are the same categories that are used in defining a Final Diagnosis, the
culmination of problem solving and problem resolution. The questions are related to
Anatomy [location and structural changes (macroscopic and microscopic)],
Pathophysiology (Disseminated intravascular coagulation), Etiology (e.g., Congenital,
Infectious, etc.), and Prognosis (based on current limitation and expected response to
maximal therapy).
We must remember that our problem solving has a purpose. That purpose is
Diagnosis and Treatment, with the latter dependent upon the former.
The following are criteria for evaluating a Problem List:
1. All of the patient data presented in the data base should be assignable to one or more
of the problems that have been identified.
2. Short informative titles should be assigned to each of the problems that have been
identified.
3. The same titles and number should be used in the future by all observers who write
in that particular patient's medical record.
4. When a new problem is added to the Problem List, it should be assigned a new
problem and title number.
5. If the new problem replaces one or more problems previously recorded on the list,
an appropriate notation should be recorded next to the initial problem (such as,
"replaced by problem ").
6. As problems evolve to syndromes or to complete diagnoses, this should be indicated
on the first Problem List by drawing an arrow from the original problem title to a new
title indicating this new state of resolution, with a date over the arrow indicating when
this new resolution was formulated or became apparent.
7. When the problem is resolved by appropriate treatment, an appropriate notation
should be made (and dated) next to the problem at its highest state of definition.
8. The permanent problem list should also note the date when each problem on the list
was first formulated.
9. When uncertain as to whether information in the data base constitutes a problem, the
physician should ask whether or not that information might be regarded as an entity
which requires a solution to help the patient.

The form that is used by students to number, prioritize, and update an Initial Problem

INITIAL PLANS
The following is a short description of the final section of the written medical history
according to the Problem Oriented format --- Initial Plans.
This section follows the Initial Problem List. It has the following format:
Initial Plans:
Problem #1: Title (from Problem List)
Assessment: Justification of a Diagnosis or Differential diagnosis with evidence for or
against, in order of importance. Rationale for overall approach to
the next section.
Plans: Dx
1.
2.
3. ...etc.
Rx
1.
2.
3. ...etc.
Pat Ed
1.
2.
3. ...etc.

The "Initial Plans" section uses ONLY information provided by the Defined Data Base
(no new history or physical findings or laboratory data can appear here if not recorded
in the Data Base). Each "Problem" from the initial Problem List becomes a title or a
heading for a section of the Initial Plans. These sections carry the same number as the
title taken from the Problem List. Each numbered problem is followed by two
subsections: the Assessment and the Plans.

The Assessment interprets and analyses the data from the Data Base. As you recall, all
"abnormal" data must either become a "Problem" on your Problem List or be dealt with
in the Assessment of another problem. In the Assessment, you review the data you
consider pertinent to the problem and you derive a series of likely working hypotheses
(diagnoses) that explain the abnormalities. These hypotheses, and the data "for" and
"against" each one, become your Differential Diagnosis.

These hypotheses permit you to rationally select among a variety of tests to confirm or
deny hypotheses and eventually select one that will become your final Diagnosis. Now,
it is possible that you have enough information in your data base (from your History,
Physical Examination, or Medical Testing (or response to therapy) to begin your Initial
Plan with a complete well-defined Diagnosis. Under this circumstance, it is unnecessary
to perform a differential diagnosis.

However, you must justify, on the basis of the data collected, your Diagnosis.
Several sentences at the end of your assessment should provide the rationale for the
subsequent plans section based on the likelihood and/or importance of one or more
diagnostic hypotheses and the immediate and long term priorities for further testing,
treatment, and patient education listed in the following section.

The "Plans" subsection follows the "Assessment". The former consists of three
parts: 1. Dx (Diagnosis) - further diagnostic evaluation; 2. Rx (Treatment) - a
treatment or therapeutic program; 3. Pat. Ed. (Patient Education) - the information
provided the patient.

The "Dx" or Diagnosis portion of "Plans" should list in order of importance your
diagnostic hypotheses, your Rule Outs (R/O's). Each R/O should be followed by the
steps of extended physical examination, further laboratory tests, or even type of
therapeutic trial you will undertake to support or deny this particular hypothesis in your
differential diagnoses. Each of these tests and/or maneuvers should be selected for their
sensitivity (few false negatives) and their specificity (few false positives). In addition,
they should be chosen in terms of their risk/benefit and of their cost/benefit.
They should also be chosen to monitor the course of an illness and/or response to
treatment interventions. In most cases, they should be performed in order to make
decisions, to act or not to act, to treat or not to treat (intervene). In fact, the whole
purpose of arriving at a diagnosis is so that you can compare your patient with others
with a similar illness, an illness with a predictable course and outcome, so that you can
make rational choices as to the therapy in a way that will modify the natural course of
the illness in a way favorable to the patient.

The "Rx" or Treatment portion of the "Plan" lists the medications and physical
measures that you will use to modify the illness and/or prevent other serious and
related consequences. This treatment must be consistent with the diagnostic
hypotheses. In many cases, response to treatment will help confirm your hypotheses. In
some cases, response to treatment will lead to a worsening of the
patient's condition, particularly if your diagnostic hypothesis is incorrect, or your
treatment really does not modify the natural history of the illness in a positive fashion
(e.g., use of leaches to treat pneumonia; the use of antibiotics to treat a viral illness).

Again, your treatment depends on your knowledge of the patient's condition. It also
depends on the value of the outcome to you and the patient and his/her family (e.g.,
intensive care for the brain-dead octogenarian vs. fetal monitoring for a high risk
pregnancy [with a history of multiple previous fetal demise]). It must also be based on
cost and risk assessment of the treatment.

Finally, the "Patient Education" section of the Plan must summarize your explanation
to the patient of his/her illness and its prognosis, the tests you plan to confirm the
diagnosis or seek a cause of the illness (their cost, risk), and the course of treatment
(again, risk, cost, and benefits). This is the hardest section to articulate in the written
record when you first see the patient; but one recognizes that one actually does the
majority of this at the bedside. It is worthwhile, while constructing your initial plans, to
consider how you are going to approach this task, and form a brief outline for the record,
demonstrating your intentions and approach in doing so. It is also true that in your
progress notes, particularly the last one, you will need to legally outline exactly what
you have instructed the patient to do in terms of diet, physical activity, and medication
at the time of discharge (your patient disposition). This has now become a near legal
obligation.

A medical record that does not document such instruction, in outline form, leaves the
practitioner open to later grief in court. A patient and family can never say "the doctor
never told me..." (e.g., about medication, etc.) if it has been documented in the chart
AT THE TIME OF DISCHARGE OR BEFORE - NOT AFTER.

In addition, the skill of your daily encouragement and instruction is a key component
and reflection of your relationship with the patient; it is also therapeutic, in and of itself.

The following is a brief example of one Initial Plan, one having to do with item
number one on this particular patient's problem list.
Initial Plans:
Problem #1: R. Pleuritic Chest Pain
Assessment:
Sharp knife-like right anterior chest pain, aggravated by inspiration,
relieved by splinting the R chest, occurring with tachypnea and hemoptysis sixteen
hours after a long plane trip suggests the likely possibility of pulmonary embolism.
However, there is no swelling or tenderness of the lower extremities or other evidence
of phlebitis. Other diagnoses include pneumonia with pleuritis (viral or bacterial) or
viral pleurisy. Against these possibilities are lack of fever, shaking chills, or increased
signs of consolidation. Costochondritis is possible but there is really no localized
tenderness of the costochondral junctions on the R. A subdiaphragmatic problem, e.g.,
abscess or ruptured viscus, is possible, but unlikely because of the hemoptysis and his
apparent respiratory distress. There is no localized tenderness to suggest rib injury or
fracture and breath sounds are heard throughout, mitigating against pneumothorax.

The following workup will emphasize R/O pulmonary embolism and bacterial
pneumonia because of their serious and immediate consequences to the patient, with
initial therapy particularly directed against possible pulmonary embolization unless this
diagnosis is excluded by further testing or by the clinical course.
Plans:
Dx
1. R/O Pulmonary Embolism - Arterial blood gases on room air and with 02 by mask.
Chest x-ray. EKG. Ventilation Perfusion scan,
including lower extremity radionuclide venogram. Consider pulmonary arteriogram if
no definitive diagnosis by scan/x-ray, or if patient requires pulmonary embolectomy.
2. R/O pneumonia - Chest x-ray, CBC. Cold agglutinins and TB skin test if infiltrate
present, along with sputum culture.

Rx
1. Continuous i.v. infusion of heparin after initial i.v. bolus. Discontinue if further
evaluation reveals other cause.
2. Monitor PTT twice daily, maintaining at 1-1/2 to 2-1/2 times control with heparin
infusion. Baseline platelet count, monitoring q 3 days for idiosyncratic decrease on
heparin therapy.
3. 02 by mask at 7 liters/min
4. Elastic stockings
5. Demerol for chest pain
Pat. Ed.
1. Explain to patient the need to perform the above tests to further define the nature of
this illness, to R/O pulmonary embolism and
pneumonia.
2. Explain heparin therapy; allude to risk/benefit and the means used above to monitor
its safe administration.

In summary, the Initial Plans section of your Problem Oriented Medical Record takes
problems at the level of resolution justified by the defined data base. It assesses each
problem, either justifying a diagnosis or suggesting a reasonable differential diagnosis
for further diagnostic evaluation. It then establishes a rationale for the course and
priorities of action as listed in Plans. The subsequent sections of Diagnosis, Treatment,
and Patient Education ends each section of the Initial Plans until all of the Active
Problems on the Problem List have all been so outlined.
 Evaluation Outline: POMR (Problem Oriented Medical Record) Outline For
Students and Clinical Skills Preceptors

Directions: Please evaluate write-ups according to

A. The format as outlined below, content and completeness of each component of the
medical history (in terms of information actually available at the time).
B. The accompanying problem list for appropriateness of title, completeness and
prioritization, as well as identifying active vs. inactive problems.
C. Assessment and plan of at least three active problem (less if fewer than 3 active
problems) following the format noted.

*****
Date/Time
Student Physician Name:
Introduction: Name, age, race/ethnicity, marital status, employment status
Reason for evaluation:
Source of Information and Reliability
Chief complaint (patient’s words, with duration)
HPI:
Chronologic order of symptoms, with as complete a characterization as possible of
each: Time of onset, setting, intensity, duration, radiation, what makes it better or
worse, with associated symptoms, as completely characterized as possible. Pertinent
data from other components of the database, e.g. past hx, family history, patient
profile, etc.
Past History (outlined)
Childhood Illness
Adult Illnesses and Hospitalizations (diagnosis, procedures, dates, locations)
Current medications: Names, doses, frequency.
Surgeries
Trauma
Allergies
Immunizations
Transfusions
Habits (Illicit Drugs, Alcohol, and cigarettes)
Family History (outlined; family tree if possible)
Patient Profile:
Living situation, typical day, diet and exercise, work situation, education, impact of
illness, insurance status.
Review of Systems:
Outline form (no need to repeat ROS components found in HPI)
Physical Examination:
Description of patient (the phrase: “Well-developed, well-nourished, in no acute
distress is not acceptable”)
Vital signs (including weight and height, if available)
HEENT
Neck
Chest (Breast exam not included now), spine
Lungs
Heart
Abdomen
GU and rectal (exams not included now)
Skin
Extremities
Neuro: Cranial nerves
Motor strength
Reflexes: normal and abnormal
Sensory

Problem List: (see separate problem list outline)

Was the Problem List Complete (all active and inactive problems identified, and
prioritized)

Assessment and Plan (for three active problems):

Problem #1
Problem Title (corresponding to Active Problems on Problem List)
Assessment: Differential diagnosis or supporting data for a definite diagnosis.
Plan: Diagnostic
Treatment:
Patient Education:

Problem #2
Problem Title (corresponding to Active Problems on Problem List)
Assessment: Differential diagnosis or supporting data for a definite diagnosis.
Plan: Diagnostic
Treatment:
Patient Education:

Problem #3
Problem Title, corresponding to Active Problems on Problem List)
Assessment: Differential diagnosis or supporting data for a definite diagnosis.
Plan: Diagnostic
Treatment:
Patient Education:

APPENDIX I
PATIENT ("PERSONAL") PROFILE OUTLINE

PAST DEVELOPMENT
Birthdate:
Birthplace:
Family:
Father (occupation)
Mother (occupation)
Siblings (number, sex, rank order of patient)
Quality of family life
Special problems
Special events
Childhood:
Location:
Quality: significant events
Adolescence: significant events
Location (If different from childhood):
When important in understanding the patient's illness, a description should be made as
to how the patient dealt with the adolescent years (special events, good & bad). The
method of separation from parental control is often significant.
Educational history: Completed high school? Where?
Past employment history:
The main emphasis is on how the patient adjusted to his work role(s) in terms of
personal gratification, interpersonal relationships, economic security and success.
Marital history: Discuss in past development only if other than present marriage.
Number
Age
Children :
number and sex
year of birth
Travel and/or other significant life events: A brief description is given of travel,
especially outside the country, particularly if any disease was contracted. Also, any
other experience such as near-death episodes of depression, major adjustments, etc.

CURRENT LIFE SITUATION

Living condition:
Home and family
Location:
Significant persons in life :
(if different than family)
Quality of life style:
Marital Hx (if not previously discussed):
Present occupation:
Discuss the overall schedule, nature of work, satisfactions, frustrations and any
occupational hazards (i.e., dust, smoke, chemicals, etc.)
Diet (typical day):
Exercise (type and amount):
Hours of sleep:
Leisure activities:
Use of ETOH (previous esp. if excessive): (now):
Use of tobacco (previous): (now-total pk/day, yrs):
Use of Prescription and/or non-prescription drugs (substances):
Financial status:
It is important to describe any financial problems that may influence the current illness
and hospitalization. If the patient is unemployed, the reasons should be determined.
Also, obtain generalities on financial responses--pensions, social security, etc.
Religious affiliation:
Insurance:
Reaction to Illness:
Some assessment should be made on how the patient feels about his/her illness and
what his/her perception is of the quality of care and overall prognosis. If very depressed,
anxious, then a more detailed inquiry should take place and be recorded appropriately.
 APPENDIX II

EXAMPLE OF PATIENT ("PERSONAL") PROFILE

PAST DEVELOPMENT:
Ms. P.F. was born on December 6, 1956 in Laconia, New Hampshire. Her father is Irish and
her mother is Italian. Both parents worked for the federal government; her father was an
engineer and her mother was in employee relations. She has two older sister, ages 35 and 33,
and a brother, age 31. The family was very close and lived in Washington, D.C. until the patient
was 14 (1970) when the family moved to Guam when her father was transferred there. She had
attended private schools in Washington, D.C. and then a public school in Guam. When her
parents divorced, there was a great deal of turmoil and she was sent to the Hawaii Preparatory
Academy. Although she missed the family, especially her brother with whom she was close,
she made many friends and graduated near the top of her class.
Immediately after graduating from high school, the patient returned to Guam where her mother
still lives. After the divorce, her father moved back to Washington D.C. where he now lives.
She enrolled in nursing school and graduated four years later. She and her mother returned to
Hawaii seven years ago and she now works in intensive care nursing.
She is single but has a boyfriend at the present time. She has not traveled outside of the United
States.
CURRENT LIFE SITUATION:
Ms. P.F. now lives with her mother in an apartment in Waikiki. She has an active social life
and has many friends. She eats very little red meat and tries to stay on a low
salt/fat/carbohydrate diet. She has a small breakfast of cold cereal and toast. Lunch is usually
a salad and dinner is often eaten out and consists mostly of fish or chicken.
She usually awakens at 9 am. She exercises by swimming, walking or biking several times a
week. She works the 3-11 shift and returns at 1 or 2 am. Ms. P.F. enjoys a regular exercise
program and likes to read mystery novels. She does not drink alcohol and does not smoke
cigarettes. She tried marijuana on one occasion as a teenager. She does not use any medications
except for occasional OTC antihistamines and has never used any illegal drugs.
She and her mother are financially comfortable and she is saving money to take a 6-month trip
around the world. She is not concerned about her medical bills since she receives free medical
care as a Kaiser employee. She considers herself a born-again Christian and is very active in
her church.
She initially was concerned that her illness might be early cancer but is now relieved that the
problem has been identified and is hopeful that the cyst can be easily and quickly removed.
Clinical Skills I – Semester 2 – 2021

Student Name :

NIM :

The Primary Medical Record – a standard framework

1. Record of Findings

Demographic Data

Name :

Age :

Adress :

Occupation :

(CC) Chief Complaint:

(HPI) History of Present Illness : details are important

SOCRATES

(PMH) Past Medical History:

(FH) Family History:

(ROS) Review of Systems:

(SH) Social History :

(PE) Physical Exam :

Record the general examination

Record the specific examination

2. Summary of Findings:
3. CLINICAL REASONING Analysis – always record your analysis

Diagnostic Reasoning

Anatomic / Physiological Dx

List a differential diagnosis

Analyze reasons

Factors from History

Factors from Physical Exam

Factors from Investigations

Provisional Diagnosis (Dx)

Therapeutic Reasoning

Natural History

Options

Arrive at a “Treatment of Choice” (Rx)

4. Review the Patient Personal Issues –ie.All the other things important to the patient

FIFE

Feelings / Fears

Insights / Ideas

Functions

Expectations

5. Recommendation : Considering “All the other Factors”,

Recommend a Management Plan

Follow Up

The Problem-Oriented Medical Record (POMR)

List the patient’s problems – you can summarize your findings as problems

Anayze the problems using (SOAP)

Subjective findings (patient’s CC, HPI, PMH)

Objective findings (Results of PE, Laboratory and imaging)

Analysis – Diagnostic Reasoning

Plan – Therapeutic Reasoning