|
|
|
 |
 |
|
Ancillary
Notes on Problem Oriented Medical Records
Notes Menu |
Glossary |
Search |
VM 551 Home |
Courses Home |
External Web
These notes discuss veterinary medical records in general.
Examples of forms at this site are from the Veterinary Teaching Hospital. Some forms are
no longer in use but remain at this site as examples. There are many different "styles" in which
medical records are written. A goal of any practice should be to have a uniform record
keeping system that is consistently used by all members of the practice. A medical
record should "speak for itself". One should be able to read a well written
medical record and without ever having seen the patient, be able to gain a comprehensive
understanding of the patient's medical care. Problem based medical records are part of a similarly named
(problem oriented) clinical reasoning process. Working with problems is not unique to
medicine. A problem based approach in engineering is referred to as systems
analysis. The problem oriented approach was first introduced to the medical fields
in the 1960's by a physician, Dr. Lawrence Weed. You may hear the POMR system referred to
as the Weed system. The POMR system is a logical system centered around the
identification and resolution of the patient's problems. The problem oriented
approach differs from other approaches in which a list of differential diagnoses are
generated in the exam room, without giving much consideration to the possibility that not
all the patient's problems are due to the same cause. Although the problem based
approach is also intended to lead to a diagnosis, the problem based approach prevents the
clinician from "jumping to a diagnosis" with tunnel vision and potentially
overlooking important aspects of the patients disease(s). Problem oriented approaches are excellent learning tools
which promote a better understanding of the pathologic and physiologic basis for disease
as well as an understanding of the relationship (or lack of relationship) between
problems. For example a patient may present with complaints of polyuria, polydipsia
and
polyphagia. The clinician may decide that based upon the last few cases (s)he has seen
with similar signs, that diabetes mellitus and hyperadrenocorticism (Cushings Disease) are
likely diagnoses. They may overlook the fact that the patient is not only urinating
large volumes (polyuria) but is also urinating frequently (pollakiuria) and with evidence
of discomfort (dysuria). Urinary tract infections occur commonly as a consequence of
both diabetes mellitus and Cushings disease. By methodically evaluating each patient
problem, pollakiuria and dysuria would be identified as unique problems, separate from the
signs more typically attributed to diabetes and Cushings (polyuria, polydipsia and
polyphagia) and the possibility of a concurrent urinary tract infection would not be over
looked. Problem based records systems can allow for easy retrieval
of data, especially when the data is computerized. For example, you may wish to
search medical records for dogs which had neutropenia regardless of cause, in order to
write a paper or to get an appreciation of the frequency of occurrence of neutropenia with
certain diseases. If only the diagnoses were recorded rather than all the
"problems" the patient had which lead to the diagnosis, it would not be possible
to gather information about specific problems from the medical record. A complete medical record will consist of several components including:
The data base is
information that is collected by the user of the medical record, either the veterinarian
or a technician. In order to collect a similar amount of baseline information about all
patients, and to avoid omissions, the minimum data base should be defined in advance and
should always be collected. A minimum data base should always include:
The
chief complaint may be very specific such as vomiting or hair loss or may be very vague
such as ADR (ain't doing right). Be careful of overinterpreting information that is told
by the client. The classic example is the use of the terms vomiting and regurgitation
which are distinctly different problems caused by different diseases but the terms may be
used interchangeably by a client. This
is the physical description of the animal including species, breed, sex, neuter status,
age and color and/or markings. The length and
depth of the history may vary with the type of problem the patient presents with. For
example, there may be a defined set of questions that are asked of the owner of a healthy
puppy or kitten including topics such as house breaking that may not be asked about sick
animals. (see VM 568 web
site for information about patient history). Specific forms are available which
contain a "checklist" of questions to ask or the history can be obtained in a
"free form" fashion or a combination of check list and freeform. A
basic physical exam can be performed in just a few minutes by an experienced clinician. It
is wise to perform a complete basic physical exam on all patients. The physical exam can
be an inexpensive but sometimes high yield procedure and forms the foundation for
comparisons on subsequent visits to the Veterinary Hospital. There are several types of
specialized exams that can be performed including neurologic exams, lameness
exams and
ophthalmologic exams. The specialized exams are performed as dictated by the
presenting complaints of the owner. See the VM 568 web site for
additional information about physical examinations. Specific forms are available on which
to record the information identified during examination. The data base may include laboratory tests, radiographs, or
other diagnostic tests. Certain types of data bases may be defined for certain classes of
patients. For example a data base may be defined based on the presenting problem and is
called a "problem-specific data base". A problem-specific data base for patients with dermatologic
complaints may include in addition to the minimum data base: map
to record location of lesions
A limited amount of laboratory data may be collected on
patients scheduled for elective surgery such as a PCV, total protein and urine specific
gravity in addition to the minimum data base whereas an extended data base including a
CBC, biochemistry profile and urinalysis may be obtained on all sick animals. The following are guidelines for the "amount" of
laboratory information that should be collected pre anesthesia for patients with various
degrees of illness.
Guidelines for Preoperative Bloodwork From the data base a problem
list is developed. A problem is anything that interferes with the patient's
well being and requires further management or evaluation. There are several types of problems including:
The problems should be stated only to the degree they are
understood. In other words do not over state problems. For example, the owner may use the
phrase regurgitation to describe vomiting. Problems can change over time and may be:
Problems are listed on a specified form in the record
called the master problem list (MPL). This list is
dynamic and will lengthen or shorten as additional problems are identified or problems are
resolved (solved). Plans are made using
information obtained from the data base(s). There are 3 types of plans:
Diagnostic plans are made in order to attempt to make a
diagnosis which will explain one or more of the animal's problems. Diagnostic plans are
made in the form of hypotheses called "rule-outs" or "differential
diagnoses". Do NOT list every possible rule out for a
problem. List 3 or 4 rule outs that are most probable for each problem, given the
signalment and environment of the patient. For example heartworm disease may be considered
a probable cause of cough in a five year old dog from Mississippi but not be considered as
a likely cause of cough in a 3 month old dog from Pullman. There are several
textbooks and computer programs than provide lists of possible causes for specific
problems. Consider the most common diseases before considering the unusual diseases: WHEN YOU HEAR HOOFBEATS........
Possible rule outs can also be generated using the damnit
acronym to guide the selection of rule outs: "DAMN IT"
acronym for causes of problems example problem: weakness Example: Hypothesize that uremia is the cause of a dogs vomiting.
Uremia is one of the possible differential diagnoses for the problem of vomiting. In order
to either incriminate or exclude uremia as the cause of the dog's vomiting you will need
to perform specific testing. The most important tests to "rule in or rule out"
uremia as the cause of the vomiting are BUN, creatinine and urinalysis. The results of
these specific tests will either prove (rule in) or disprove (rule out) the hypothesis
that uremia is the cause of vomiting in this patient. Plans are also made for treatment and
plans can be made to communicate findings to the owner. These plans are therapeutic plans
and client education plans, respectively. There are several types of treatment including: surgical
removal of a tumor
fluid and electrolytes therapy for the patient with
hypoadrenocorticism
antiemetics to suppress vomiting Progress Notes
are the method used to record information which is planned or performed. Progress notes
are written in the form of SOAPs. S = Subjective What the patient tells the Doctor. As
our patients don't usually talk, subjective information is limited. Some people write
subjective assessments such as bright and alert or depressed as subjective data. O = Objective Numbers and other "hard"
data... a BUN of 56mg/dl, a grade II/VI heart murmur. A = Assessment This is your interpretation of the
data. What is the significance of the BUN of 56 mg/dl? P = Plans What are you going to do next? Are you
going to start a treatment? Do you need to perform additional lab tests? At least one SOAP is written for each active problem daily.
For rapidly changing problems may need more than one SOAP daily. For some problems the
SOAP will remain unchanged for several days. Other progress notes include
In order to facilitate easy reading of a record, all
records in the hospital should be arranged in the same order.
Follows is an example of record order:
This is an overview of how to use
the POMR system using the example presented in class: Each section in the hospital at WSU
may use variations of the following.
Signelment: "Foxy Lady" History: The owners noticed
"lumps" under Foxy's neck a few days ago. She has been drinking and urinating
"a lot" for the past few weeks. Her right eye looks red and "bulgy".
She has vomited a few times over the past week and her appetite is reduced. She has been
scratching her left ear for the past week. Physical Exam: All
peripheral lymph nodes are ~4-5 times normal size. She is ~8% dehydrated based on skin
turgor. There is a 4 x 4cm firm, raised, hairless lesion on the lateral aspect of the left
elbow. The conjunctiva and nicitans of the right eye are red and swollen. There is
ceruminous exudate in the left ear. Day 1 - define problems obtained from history, physical
exam, and any initial lab work. Foxy Lady's initial problem list
Day 1 - on a physical exam sheet or on a SOAP sheet, list each problem followed by the most likely rule outs for that problem with a short diagnostic plan for each rule out: Do not list every possible rule out for a problem. List 3 or 4 rule outs that are most probable given the signalment and environment of the patient.
Formulate a R/O list and DX plan for each problem. THEN.... Look for the occurrence of the same R/O's (diseases) on multiple lists. These are the diseases on which you should focus your initial diagnostic efforts. Remember that not all the problems may be caused by the same disease. Not all diagnostic plans will actually be performed. It is important to differentiate in the patient record which tests were considered and which were actually performed. This is usually done by placing a check box adjacent to tests that are performed and checking the box and signing as the test is performed. Subsequent to day 1, a master problem list is generated and each problem on Master Problem List (MPL) which remains active gets at least one SOAP daily. If several problems can be grouped together under one disease ® update MPL and SOAP as one new problem.
SOAP for problem #2, PU-PD S.depressed O. BUN = 90 mg/dl, Creat = 5 mg/dl, USG = 1.012, Ca++ = 17 mg/dl A. The presence of azotemia in conjunction with isosthenuric urine confirms kidney failure. This patient has hypercalcemia; calcium is nephrotoxic and can directly interfere with renal concentrating mechanisms. As this patient has LSA, the increased calcium is a paraneoplastic condition resulting in renal failure (pseudohyperparathyroidism). P. DX: update on MPL to Lymphosarcoma RX: saline fluid therapy to reduce serum calcium. See problem # 7, dehydration, for fluid therapy plans. CE: The hypercalcemia can be normalized with chemotherapy. The renal damage may or may not be reversible. If a problem is not to be pursued, write one SOAP to explain "why" and then inactivate on MPL and do not SOAP again. As new problems arise, a SOAP is written for each. Use the "A" (assessment) for rule outs for each new problem and the "P" for the Dx plan for those rule outs. The master problem list should reflect changes in the status of the problems. There is more than one way to generate a master problem list:
MPL = Master Problem List Notes Menu | Glossary | Search | VM 551 Home | Courses Home | External Web This page was last edited on
August 04, 2005 by CRD |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
