Problem Oriented Medical Record definition

Problem Oriented Medical Record format is utilized throughout Xxxxx County system. The health record will contain the following information: ● Identifying information (e.g. inmate name, alias, ID #, date of birth) ● Completed Receiving Screening form ● Medical Evaluation Report ● All findings, diagnosis treatments and dispositions ● Problem list ● Medication Administration Record ● Laboratory, X-ray and diagnostic studies ● Signed Informed Consent ● Refusal forms ● Place, date and time of all health encounters ● Dental consultations/treatments ● Psychiatric evaluations and treatments ● Hospital Discharge Summaries ● Transfer forms ● Individual treatment plans as required ● Allergy alert
Sample 1

Examples of Problem Oriented Medical Record in a sentence

  • The Problem Oriented Medical Record, also known as the Subjective, Objective, Assessment and Plan (SOAP) format, shall be used as the standard form for keeping records.

  • Weed’s Problem Oriented Medical Record [7] and Fries’ Time Oriented Record [8] were both designed to organize in- formation in a way that would render it accessible to readers, beneficial to writers, and useable by programmers.

  • Providing adequate, legible, appropriate, and timely documentation for all patient encounters in the medical record in Problem Oriented Medical Record format.

  • For purposes of standardization of medical records, Wexford personnel are to use the Problem Oriented Medical Record (“POMR”) method, and follow the Subject, Objective, Assessment, and Plan (“SOAP”) format.

  • All other information in the EHR is conveyed through combinations of general codes from clinical terminologies and time-stamping information.In the type of EHR we have in mind, in contrast, the particular schizophrenia itself – which is to say, this particular case or instance of this disease in this particular patient – would also receive its own unique ID, and this within a more detailed context than under the Problem Oriented Medical Record approach [8].

  • Ideally, the discharge summary should follow the format of the Problem Oriented Medical Record in which individual problems are defined, analysed, and their final disposition described.

  • Following the Problem Oriented Medical Record (POMR), all the patient information regarding symptoms, medical observations, diagnoses, and treatment plans are stored inside that structure.Although these systems allow the insertion of free text and other non-universal information, the AIDA and AIDA-PCE present innovative and novel solutions to accomplish interoperability.

  • We want to give you some practice and some specific feedback on writing a Problem Oriented Medical Record – including the analysis and integration of clinical problems, writing and managing a Master Problem List (MPL), capturing your thought processes and client communications, constructing a Master Plan, interpreting laboratory data, and resolving a record at the end of a case.

  • It is an organizational transformation of medicine that was begun by Dr Lawrence Weed with his Problem Oriented Medical Record.

  • For the Sheriff, the Contractor shall maintain a comprehensive, accurate, and integrated medical health, behavioral health, and dental medical record for every detainee consistent with applicable law and based on the Problem Oriented Medical Record approach to documentation.

Related to Problem Oriented Medical Record

  • Medical record means any document or combination of documents, except births, deaths, and the fact of admission to or discharge from a hospital, that pertains to the medical history, diagnosis, prognosis, or medical condition of a patient and that is generated and maintained in the process of medical treatment.

  • Medical Records the Study Subjects’ primary medical records kept by the Institution on behalf of the Study Subjects, including, without limitation, treatment entries, x-rays, biopsy reports, ultrasound photographs and other diagnostic images. Zdravotní záznamy: primární zdravotní záznamy Subjektů studie vedené Zdravotnickým zařízením ve vztahu k Subjektu studie, zejména záznamy o poskytnuté péči, zázanym o RTG vyšetřeních, protokoly o provedených biopsiích, snímky z ultrazvukových vyšetření a další snímky diagnostické povahy. Study Data: all records and reports, other than Medical Records, collected or created pursuant to or prepared in connection with the Study including, without limitation, reports (e.g., CRFs, data summaries, interim reports and the final report) required to be delivered to Sponsor pursuant to the Protocol and all records regarding inventories and dispositions of all Investigational Product. Studijní data a údaje: veškeré záznamy, zprávy a protokoly, jež jsou odlišné od Zdravotních záznamů, a které jsou získány, shromážděny či vytvořeny v návaznosti na či připraveny v souvislosti se Studií, zejména zprávy, záznamy a protokoly (např., CRFs, datové přehledy, mezitímní zprávy a protokoly, a závěrečná zpráva), které jsou požadovány, aby byly poskytnuty Zadavateli v souladu s Protokolem a veškerými záznamy ohledně inventurní evidence a nakládání s veškerým množstvím Hodnoceného léčiva.

  • Clinical record means a legible electronic or hard-copy history that documents the criteria established for medical records as set forth in rule 441—79.3(249A). A claim form or billing statement does not constitute a clinical record.

  • Database Management System (DBMS) A system of manual procedures and computer programs used to create, store and update the data required to provide Selective Routing and/or Automatic Location Identification for 911 systems. Day: A calendar day unless otherwise specified. Dedicated Transport: UNE transmission path between one of CenturyLink’s Wire Centers or switches and another of CenturyLink’s Wire Centers or switches within the same LATA and State that are dedicated to a particular customer or carrier. Default: A Party’s violation of any material term or condition of the Agreement, or refusal or failure in any material respect to properly perform its obligations under this Agreement, including the failure to make any undisputed payment when due. A Party shall also be deemed in Default upon such Party’s insolvency or the initiation of bankruptcy or receivership proceedings by or against the Party or the failure to obtain or maintain any certification(s) or authorization(s) from the Commission which are necessary or appropriate for a Party to exchange traffic or order any service, facility or arrangement under this Agreement, or notice from the Party that it has ceased doing business in this State or receipt of publicly available information that signifies the Party is no longer doing business in this State.

  • Authorized medical physicist means an individual who:

  • Medical assessment means an assessment of a patient’s medical condition secured by our Assistance Company working in conjunction with the Medical Evacuation Provider’s medical director and in collaboration with the attending physician. The Assistance Company in collaboration with the Medical Evacuation Provider, will utilize the assessment to determine at its sole discretion whether a Plan Holder is fit to fly; the most appropriate means to provide medical evacuation; the medical personnel who will be accompanying the patient on the transport; and to confirm the medical facility closest to one’s home can meet their medical needs. If the patient’s medical facility of choice is unable to provide the high level of medical care required by the patient, arrangements will be made to transport the patient to the appropriate medical facility closest to their home, or closest to patient's preferred medical facility in the US when possible.

  • Research record means any data, document, computer file, computer diskette, or any other written or non-written account or object that reasonably may be expected to provide evidence or information regarding the proposed, conducted, or reported research that constitutes the subject of an allegation of research misconduct. A research record includes, but is not limited to, grant or contract applications, whether funded or unfunded; grant or contract progress and other reports; laboratory notebooks; notes; correspondence; videos; photographs; X-ray film; slides; biological materials; computer files and printouts; manuscripts and publications; equipment use logs; laboratory procurement records; animal facility records; human and animal subject protocols; consent forms; medical charts; and patient research files.

  • Database Management System (“DBMS”) is a computer process used to store, sort, manipulate and update the data required to provide Selective Routing and ALI.

  • Medical cannabis card means the same as that term is defined in Section 26-61a-102.

  • Educational records means: those official records, files, and data directly related to a student and maintained by the school or local education agency, including but not limited to records encompassing all the material kept in the student's cumulative folder such as general identifying data, records of attendance and of academic work completed, records of achievement and results of evaluative tests, health data, disciplinary status, test protocols, and individualized education programs.

  • Analytical x-ray system means a group of components utilizing x-rays to determine the elemental composition or to examine the microstructure of materials.

  • Health record means the same as that term is defined in § 32.1-127.1:03.

  • Patient Record means a written account of all services provided to a patient by the home health agency, as well as other pertinent information necessary to provide care.

  • Prescription monitoring program means the electronic system within the Department of Health Professions that monitors the dispensing of certain controlled substances.

  • Statistical record means a record in a system of records maintained for sta- tistical research or reporting purposes only and not used in whole or in part in making any determination about an identifiable individual, except as pro- vided by 13 U.S.C. 8.

  • Medical marijuana waste or "waste" means unused,

  • School-sponsored media means all student media that are:

  • Nuclear pharmacy means a pharmacy providing radio-pharmaceutical service.

  • Medical cannabis means the same as that term is defined in Section 26-61a-102.

  • Functional behavioral assessment means an individualized assessment of the student that results in a team hypothesis about the function of a student’s behavior and, as appropriate, recommendations for a behavior intervention plan.

  • Medical Specialist means any medical practitioner who is vocationally registered by the Medical Council under the Health Practitioners Competence Assurance Act 2003 in one of the approved branches of medicine and who is employed in either that branch of medicine or in a similar capacity with minimal oversight.

  • Public safety answering point (PSAP) means a 24-hour, state, local, or contracted communications facility, which has been designated by the local service board to receive 911 service calls and dispatch emergency response services in accordance with the E911 service plan.

  • Emergency Medical Transportation means the transportation, by ambulance, of sick, injured or otherwise incapacitated persons who require emergency medical care.

  • Medical history means information regarding any:

  • Emergency medical care means such medical procedures as:

  • Education Record means those records that contain information directly related to a student and which are maintained by an education agency or institution or by a party acting for the agency or institution.