NCJ Number
68816
Date Published
Unknown
Length
55 pages
Annotation
THE MANUAL SERVES AS A REFERENCE FOR THE PRISON HEALTH CARE PROFESSIONAL IN UNDERSTANDING THE PROBLEM-ORIENTED MEDICAL RECORD (POMR) APPROACH AND AS A MODEL FOR THE PROCESS OF RECORDS RESPONSIBILITY.
Abstract
POMR IS THE MOST SUITABLE RECORD FORMAT FOR PRISON HEALTH CARE BECAUSE OF ITS CLEARNESS, ITS ABILITY TO SERVE AS A DYNAMIC COMMUNICATION TOOL FOR THE ENTIRE HEALTH TEAM, AND THE EASE WITH WHICH THE DATA CAN BE ABSTRACTED FOR QUALITY AUDITING. FURTHER ADVANTAGES ARE ITS USEFULNESS AS A RESEARCH TOOL AND IN PROTECTING THE LEGAL INTERESTS OF PERSONS WHOSE NAMES APPEAR IN THE RECORDS. MANAGEMENT PRINCIPLES MUST BE OBSERVED WHEN INSTITUTING POMR. A SINGLE FILE IS NEEDED FOR ALL MEDICAL RECORDS, AND MEDICAL RECORDS AND CONFINEMENT FILES SHOULD BE KEPT SEPARATE. CONFIDENTIALITY MUST ALWAYS BE PROTECTED, AND DOCUMENTATION OF EVERY PATIENT-PRACTITIONER MUST BE KEPT. MEDICAL RECORD REVIEW OCCURS AT EACH ENCOUNTER AND THE RECORDS FOLLOW THE INMATES IF THEY ARE TRANSFERRED TO A NEW INSTITUTION. THE TECHNICAL PROCESS OF POMR INVOLVES AN INITIAL DATA BASE, A PROBLEM LIST COMPILED FROM THE INITIAL DATA BASE AND FROM SUBSEQUENT MEDICAL ENCOUNTERS, INITIAL PLANS OF MEDICAL ACTION, AND PROGRESS NOTES DOCUMENTING EACH MEDICAL ENCOUNTER. FLOWSHEETS ARE USEFUL FOR PATIENTS REQUIRING A COMPARISON OF MULTIPLE VARIABLES OVER TIME. DISCHARGE SUMMARIES DOCUMENT THE OVERVIEW OF THE HOSPITAL COURSE AND ARE COMPLETED AT THE END OF INPATIENT HOSPITALIZATION. A MODEL FOR CONDUCTING CHANGE EFFORTS DURING THE INTRODUCTION OF POMR SYSTEM INVOLVES THREE PHASES: ESTABLISHING AN OPERATING BASE, TEACHING THE POMR METHODOLOGY, AND IMPLEMENTATION AND EVALUATION. SAMPLE HEALTH RECORD FORMS AND PRACTICE EXAMPLES ARE PROVIDED. A BRIEF BIBLIOGRAPHY AND A RESOURCE LIST ARE APPENDED.