9.9 : 文書化の方法 II: POMR

The problem-oriented medical record or POMR focuses on patients' problems; for this, each healthcare team member records their collective information in the same form.

The POMR has four essential components.

First is the database, which records crucial medical details about the patient, including their medical history, current medications, allergies, and physical examination findings.

The report also comprises data regarding social history and preliminary diagnostic tests.

Second, the problem list consists of significant aspects of the patient's life that require medical attention, including socioeconomic, psychological, and physiological problems. Each problem has a label and number, categorized as active or inactive.

Third, the plan of care includes a treatment plan for each problem. It consists of interventions and treatments.

Lastly, progress notes document the patient's ongoing treatment progress, including any changes in the treatment plan or new problems.

The advantage of POMR is that it provides complete and accurate information, enhancing care continuity.

One drawback is its focus on treating issues individually rather than considering the patient as a whole.