The patients otherization medical regestration
The patients otherization medical regestration
SOMR (Source-Oriented Medical Record) organizes patient information by different sources of data, such as lab results, medications, and nursing notes, making it easier to track specific disciplines. In contrast, POMR (Problem-Oriented Medical Record) structures information around the patient's problems, facilitating a comprehensive approach to diagnosis and treatment by focusing on individual issues and their management. The POMR method encourages a more holistic view of patient care, while SOMR is more fragmented and source-specific.
Medical records at Willow Nursing Home have the following format: database, problem list, initial plan, and progress notes. What type of record format is this? This type of record format is called C. Problem-oriented
In a POMR or problem oriented medical record, the record is kept together by problem number (a number is assigned to each problem. Progress notes in these records are kept in SOAP format. S=subjective (chief complaint, present illness), O=objective (physical exam, labs), A=assessment (diagnosis, prognosis), P=plan (treatment). In a SOMR or source oriented medical record, the record is kept together by subject matter (labs are all together, progress notes are all together). Progress notes in a SOMR are written in paragraph format.