The Problem Oriented Medical Record

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The Problem OrientedMedical Record
Introduction to Primary Care a course of the
Center of Post Graduate Studies in FM
PO Box 27121 Riyadh 11417 Tel [phone] Fax
4970847
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Aim-Objectives

• Objectives
• be able to define source oriented medical record
• be able to define problem oriented medical record
• be able to list items to be included in the
  medical record
• be able to discuss reasons for keeping medical
  records
• be able to explain the PSOAP acronym for keeping
  records

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It is always easier to find your way if you have
a road map!
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Which data are we recording in practice?
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Why to keep records?

• Helps in medical decisions
• (is the size of a lymph node or nodule
  increasing with time?)
• Helps to share responsibility with the patient
• Legal obligation.
• Protects the patient as well as doctor in front
  of the court

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Why to keep records?

• Has economic benefits
• Useful to produce health statistics
• Provides epidemiological data
• Assists practice management
• Useful in QI activities
• Is a communication tool
• Useful in medical education

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Types

• According to the method
• Source oriented
• Problem oriented

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• Source oriented medical record Data taken from
  the source are recorded as they are (Source
  patient, relative, laboratory etc.)
• Easy and fast to record
• Flexible
• Omitting information is highly possible
• Difficult to access the information

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• Problem oriented medical record
• Structure is defined in advance.
• The patient with problem is in the focus
• It is systematic
• Data is easily accessible
• Starts with a problem list
• Progress notes are according to the PSOAP acronym
• Patients problem is in the front line
• Not flexible. Recording information is difficult
  and time consuming

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Which data to record?
Personal info age, sex, occupation, training, family...
Risk factors tobacco, alcohol, life styles...
Allergies and drug reactions
Problem list
Disease history diseases, operations
The disease process main problem, history, exam, lab.
Management plan advice, education, medication
Progress notes in the P S O A P format
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PSOAP
Problem Everything the patient reports and doctors findings which are regarded as problems
Subjective History of the problem what the patient feels or thinks about the problem
Objective Doctors findings related with the problem
Assessment Evaluation of the problem the diff. diagnosis
Plan Prescription, consultation, advice, control visit.
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Source Oriented Medical Record
Visits 21 February 2006 dyspnea, coughing and
fever. Dark defecation. PE BP 150/90, pulse
95/min, Fever 39.3 oC.Ronchi , no abdominal
tenderness.Medications 64 mg Aspirin/day.
Possible acute bronchitis and cardiac
decompensation.Possible bleeding due to
Aspirin.Rx Amoxicilline 500 mg 2x1, Aspirin 32
mg/day. 4 March 2006 no cough, slight dyspnea,
defecation normal.PE light rhonchi, BP 160/95,
pulse 82/min.Rx Aspirin 32 mg/day. Lab 21
February 2006 ESR 25 mm, Hb 7.8, Fecal occult
blood . 4 March 2006 Hb 8.2, Fecal occult blood
-. X-ray 21 February 2006 Chest x-ray no
atelectasis, light cardiac decompensation findings
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Problem Oriented Medical Record
Problem 1 Coughing 21 February 2006 S dyspnea,
coughing, fever. O pulse 95/min, Fever 39.3
oC. Rhonchi. ESR 25 mm. Chest x-ray no
atelectasis, light cardiac decompensation
findings. A Acute bronchitis. P Amoxicilline
500 mg 2x1. 4 March 2006 S no coughing, slight
dyspnea. O pulse 82/min. Slight rhonchi. A
minimal bronchitis findings.
Problem 2 Dyspnea 21 February 2006 S
Dyspnea. O Rhonchi, BP 150/90 mmHg. Chest
x-ray no atelectasis, slight cardiac
decompensation findings. A Slight decompensation
findings. 4 March 2006 S slight dyspnea. O BP
160/95, pulse 82/min. A No decompensation.
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 Problem 3 Dark colored defecation 21 February
2006 S Dark feces. Using Aspirin 64 mg/day. O
No abdominal tenderness, rectal exam revealed no
blood, Hb 7.8 mg/dl. Fecal occult blood A
Possible intestinal bleeding due to Aspirin. P
Decrease Aspirin dose to 32 mg/day. 4 March
2006 S Defecation normal. O Fecal occult blood
- A No intestinal bleeding symptoms. P Continue
Aspirin dosage 32 mg/day
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Rules in keeping medical records (NCQA)

1. Patients name or ID number.
2. Personal biographical data
3. Authors identification
4. All entries are dated.
5. The record is legible to someone other than the
   writer.
6. Problem list.
7. Medication allergies and adverse reactions

http//www.ncqa.org/LinkClick.aspx?fileticketdmQO
rIgyvMQ3Dtabid125mid766forcedownloadtrue
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National Committee for Quality Assurance (NCQA)

1. Past medical history
2. For patients 12 years and older, there is
   appropriate notation concerning the use of
   cigarettes, alcohol and substances
3. The history and physical examination
4. Laboratory and other studies are ordered, as
   appropriate.
5. Working diagnoses are consistent with findings.
6. Treatment plans are consistent with diagnoses.
7. Encounter forms or notes have a notation,
   regarding follow-up care, calls or visits, when
   indicated.

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NCQA

1. Unresolved problems from previous office
2. There is review for under - or over utilization
   of consultants.
3. Note from the consultant in the record.
4. Consultation, laboratory and imaging reports
   filed in the chart are initialed by the
   practitioner who ordered them, to signify review.
   
5. There is no evidence that the patient is placed
   at inappropriate risk by a diagnostic or
   therapeutic procedure.
6. Immunization record
7. Preventive screening and services

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Legal Problems

• Not recorded Not done !

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In order to prevent legal problems

• Record everything you do (including phone
  consultations)
• Apply guidelines (e.g. NCQA)
• Don't use erasable pencils
• Dont use humiliating expressions

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• Do not use vague expressions such as the patient
  feels well
• If you need to make changes just strike through
  and record also the date of change
• If you stated that the patient is not cooperative
  give the reason
• If patient rejects a procedure or test, mention
  it and give the reason why you requested it

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Follow-up Charts

• It is practical to use follow-up charts for
  chronic diseases
• DM,
• Hypertension
• Obesity

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Charts - Obesity
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Medical Records are Our Road Maps
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Summary

• What are the benefits of keeping records?

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• Can you explain the meanings of PSOAP in the
  medical record?

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• What are the core elements requested by NCQA in
  the medical record?

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THANK YOU
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