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Day 2 & Beyond

The Medical Record

During each submission deadline a completed Medical Record needs to be submitted by your clinics.

To aid in the process, the students have been asked to keep their medical records organized, complete, and free of excess paper. This can allow you to fully evaluate their record and follow their thought process.

POMR is usually organized from front to back as:

  • Master Problem List (updated daily & always on top)
  • History (completed VTH form)
  • Physical Exam (completed VTH form)
  • Daily Progress Reports (SOAP's)
  • Laboratory Data (results)
  • Miscellaneous - client communication form, client instruction forms/letters, etc.

Additional DC References:

Washington State University