Computer-generated progress notes in an automated POMR.

Abstract

Herein we describe an innovative, computerized version of Problem Oriented Medical Records (POMR). This expanded variation of the Weed system is currently being used by primary care physicians on a regular basis with excellent results. The method is an extension of the POMR system of keeping medical records, augmented in the manner of McDonald for computer-generated reminders. Separate files are maintained for the patients, the diagnoses, and the medications. At each patient "encounter," reminders from the diagnosis file are printed for each active diagnosis for the patient. These reminders are grouped into initial data bases and follow-up data bases. For each "diagnosis-specific data base," both subjective and objective reminders are printed. Similarly, follow-up data reminders for medication surveillance are displayed.