Documentation System

Source-Oriented Record: (Traditional)

• Each person or department makes a separate section or sections of the client's chart (admission sheet, doctor order sheet, nursing assessment, diagnostic report, discharge plan, nurses' notes).

Problem-Oriented Medical Record (POMR):

• The data is arranged according to the problems the client has rather than the source of the information.

Advantages of POMR

1. It encourages collaboration.

2. The problem list in the front of the chart alerts caregivers to the client's needs and makes it easier to track the status of each problem.

Disadvantages of POMR

1. Caregivers differ in their ability to use the required charting format.

2. It requires constant attention to maintain an up-to-date problem list.

Somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated.

4 Basic Components of POMR

1. Database: Consists of all information when the client first enters the healthcare agency. It includes:

1. Nursing assessment

2. Physician history

3. Social and family data

4. Results of physical examination

5. Baseline diagnostic tests

2. Problem list: Derived from the database.

1. Impaired physical mobility

2. History of hypertension

3. Constipation

3. Plan of care: Care plans are generated by the person who lists the problems.

4. Progress notes:

1. Chart entries made by all health professionals involved in the client's care.

2. Numbered to correspond to the problems on the problem list.