JMIR Publications

ABSTRACT

Background:

Problem-oriented medical record (POMR), which incorporate the SOAP format, are regarded as the de facto standard for physicians’ clinical notes. However, since 2010, variations of POMR (hereafter, modern POMR) that differ from the original POMR proposed in the 1960s (classical POMR) have been reported. In practice, physicians’ clinical notes often differ from both forms of POMRs, and many notes are copied and pasted. Thus, POMRs have characteristics that hinder their effective adoption in clinical practice.

Objective:

This study aimed to investigate the characteristics of POMRs that hinder their adoption in clinical practice.

Methods:

We adopted a qualitive research method as an approach suitable for characterizing the properties of existing concepts in literature. The literatures of medical records were gathered manually. After selection, the papers were grouped, and their characteristics were analyzed from the perspectives of the background of the proposed documentation methods, the authors’ philosophies, the purpose of documentation, contents, and the advantages and disadvantages of its digitization.

Results:

Ten papers (four classical POMR; six modern POMR) were selected and classified into six types. Five features common to all types were identified: (1) documentation takes priority over the provision of medical care, which should be the physician’s primary responsibility; (2) the definitions of problems addressed are inconsistent; (3) the fundamental premises of the clinical care model are unclear; (4) adherence to an early methodology (before 1935) that records only differences in the patient’s course; and (5) failure to utilize the advantages of digital data, which can be duplicated. This study addressed deficiency (3) by identifying the clinical care model underlying POMRs and explicitly naming it the “Updated Clinical Care Model.”

Conclusions:

This study identified five shortcomings that hinder physicians from documenting clinical notes according to POMRs. Redesigning electronic health record systems based on the underlying clinical model identified in this study may offer an alternative to copying and pasting documentation and facilitate documentation that is consistent with POMRs.