The problem-oriented medical record: evaluation and management of anemia before and during use

Abstract

The problem-oriented medical record (POMR) is designed to rationalize and improve the structure of the medical record. This change might be expected to enhance the outcome of patient care. Therefore, I assessed the effect of the POMR on the care of the problem--anemia--in a Veterans Administration teaching hospital. The POMR concept was introduced by lectures and supported by chart audit. Four months later, the care described in 29 sequential records containing the discharge diagnosis--anemia--was compared with 31 records produced at the same period in the previous year by house officers not using the POMR. Records were graded for maintenance of the POMR format. Completeness of the "data base," as well as time to problem identification, therapy, and diagnostic description were compared. Introduction of the POMR had no observable beneficial effect on the thoroughness of data base accumulation or the process of patient care for the problem (anemia) or, in another study, on the ease or accuracy of chart audit.