Format review: evaluating implementation of the problem-oriented medical record.

Abstract

As interest in the problem-oriented medical record (POMR) develops, and more medical settings begin to implement the system, many observers are expressing a desire to know how well the system is being used and accepted. Moreover, settings currently using the POMR system have a need to document the effectiveness of their POMR program as a means of insuring continued progress and for addressing difficulties and obstacles affecting its use. Format review is a technique for reviewing patient records and describing patterns of POMR use. Patient records of an institution are reviewed concurrent to the patient's contact with the institution. Data collected from each record is summarized to provide an overview on patterns of POMR use and to identify areas of difficulty. These findings can serve as the basis for educational and administrative intervention to improve use of POMR. The format review technique is explained and examples of its application are given. The technique has been used at Michael Reese Hospital and Medical Center over the past two years, and has proven to be a useful tool in describing the implementation progress of POMR.