The problem-oriented medical record (POMR) was developed by Dr.Lawrence L. Weed. The POMR is based on the client\'s problems, andevery health-care employee, including the provider, adds to thechart in a particular place in the same manner. The POMR identifiesthe client\'s problems, not simply diagnoses that are based ondefined data. A problem can be a condition or a behavior thatresults in physical or emotional distress or interferes with theclient\'s functioning.

Examples include pain in the knees and ankles, fear of falling,decreased appetite, and even an inability to pay medical bills. Theproblem list is usually numbered, appears early in the recordusually on the chart face sheet, and serves as a checklist toascertain the client\'s progress.

To identify clients’ problems, the provider explores theclient\'s problem and performs services that may include a physicalexamination, history, laboratory tests, and obtaining subjectivedata from the client. Every problem has a plan, and its progress isrecorded in the medical record.

Weed also developed a computerized medical record that permitsthe healthcare provider to build a computer-based POMR whileaccessing data pertinent to the problem from currentliterature.

Class,
What authorization is required to release clients’ medicalrecords? Who owns them? Are these concerns healthcare employeesface daily?

Answer rating: 100% (QA)

Answer The patient or their designated representative must give permission before clients medical re... View the full answer