problem-oriented medical record


record

 [rek´ord] 1. a permanent or long-lasting account of something, such as in writing or on film.2. in dentistry, a registration" >registration.bibliographic record an index record standing for or representing a journal article, book, or other document.Problem-Oriented record (Problem-Oriented Medical record) see problem-oriented record.

problem-oriented medical record

A medical record in which each Pt's condition or complaint is formally addressed; a POMR may be organized by the acronym of SOAP–subjective criteria, objective criteria, assessment, plan. See Hospital record, Medical record, SOAP.

prob·lem-o·ri·ent·ed med·i·cal re·cord

(POR, POMR) (prob'lĕm-ōr'ē-en-tĕd med'i-kăl rek'ŏrd) A medical record model designed to organize patient information by the presenting problem. The record includes the patient database, problem list, plan of care, and progress notes in an accessible format.