Problem Oriented Medical Record

Clinical Actions

The most important clinical actions are not procedures or prescriptions, but the judgments from which all other aspects of clinical medicine flow Diagnosis , diagnosis, and diagnosis

Daniel B Mark, 2008

Hypothesis testing

Diagnosis

Treatment planning

Learning process

Patient management

Learn the disease based

data

Pathophysiology

Etiology

Hypothesis

Problems manifestation

Morphology, cell,

biochemical changing

Structure and function

disturbances

Learn the patients based

data

Sign & symptoms

Newly data

Newly data

Perspective

In pathology we learn disease In clinical training we work with illness Ideally, the physician will think in terms of

both disease and illness Each such illness is a unique event. It

happens to a single individual over restricted period of time and will never happen again in precisely the same way

Disease, is an abstraction, illness is a process

Perspective Students who never conceptualize the

distinction between disease and illness will make two errors

First, is to mistake the disease as a reality BP 150/90 becomes a disease rather than sign

of possible illness. If no other cause can be found, the patient is given a disease label, never mind that the patient is 90 years old the physician who has balances view of disease and illness will see the elevated BP as only a sign of disease, not the itself.

Second, is not to see the illness at all. There is indisputable merit in understanding

the total social and psychological forces impinging on the patient.

Pemahaman Umum

• Data : raw material• Masalah : sesuatu yg harus ditindak

lanjutio Masalah test menuju DXo Diagnosis terapi

• Test : accuracy• Probability : diagnosis diferensial• Kriteria Dx : diagnosis pasti• Treatment : evidence based

• Catatan : kumpulan data pengkajian diagnosis pengkajian Tx

Scientific MethodProblem Identification

Data Collection

Data Analysis

Synthezise Data

Hypothesis

Solution implemented

New Data

Planning Solution

Decision makingDecision making

SPSA

Scientific Problem Solving

• Problem solving• Problem solving approach• Scientific problem solving

approachScientific problem solving approach1. roblem identification2. Data gathering3. Data analyzing4. Data synthesizing5. Problems formulation6. Problems solving7. Monitoring and evaluation

Scientific Method

Identify the Problems

Collecting Data

Synthesis the Data

Hypothesis Developmen

t

Verification

Proved Hypothesis

New Hypothesis

Decision Making-For Dx tools- For Tx regimens- For prognostic

Solve the Problem

SCIENTIFIC PROBLEMS SOLVING

APPROACH

S.P.S.A.

PROBLEM IDENTIFICATION

EVALUATION DATA COLLECTION

IMPLEMENTATION DATA ANALYSIS

PRIORITY SETTING HYPOTHESIS FORMULATION

PROBLEM SOLVING HYPOTHESISALTERNATIVE TESTING

CLINICAL PROCESS

HEALTH PROBLEM

FOLLOW-UP ANAMNESA/ P.D./ LAB. / MED-

RECORD

IMPLEMENTATION DATAS &

INFORMATION

ANALYSIS

TREATMENT DIAGNOSIS PRIORITY SETTING SYNTHESIS

TREATMENT DIAGNOSIS ALTERNATIVESPLANNING

Scientific Thinking Paradigm

major to minor

minor to major

Hypothetic Verification

Deductive

Inductive

?In the clinical setting

The patient

The health problems

Is it real problem?

Come to health center

Solve the problem

Decision making

Decision making

The Similarity of Hypothesis & Diagnosis Testing

• Hypothesis testing • Diagnosis testing

Learn the patient

Learning of disease

Diagnosis / DD

Verification

• observe the patient• sensitivity / specificity of test

New informatio

n

Research data

Learning concept

hypothesis

Hypothesis test

• survey• experiment

New evidence

The Step in Reaching Diagnosis

COLLECT INFORMATION

VERIFY INFORMATION AND CHECK IT’S CONSISTENCY

FORMULATE A DIFFERENTIAL

DIAGNOSIS

NEED MORE INFORMATION

IDENTIFY THE PROBLEM

• history taking• physical Examination•Laboratory/others data

FORMULATE A THERAPEUTIC

REGIMEN

Decision making

Decision making

Clinical Process

Diagnosis Process

Therapeutic Process

Clinical Process

Complains Diagnose Treatment

DiagnosisProcess

Clinical Process

Therapeutic process

BAGAN POMR

2. Identifikasi Masalah / Problem

1. PengumpulanData (Anamnesis, Pem.fisik, Lab, Foto dll )

3. Hipotesis Initial Diagnosis

5. Kesimpulan (diagnosis tetap)

4. Pengujian Hipotesis

Pengumpulan data

tambahan melalui Planning : - Anamnesis - Pemeriksaan fisik - Laboratorium - Foto / dll.

6. Terapi

TAHAP – TAHAP P O M R

Data Dasar

Ax

Px

Lab

Px Tambahan

Interpretasi Data Abnormal

Daftar masalah sementara

Abnormal

Abnormal

Abnormal

Abnormal

Sintesis

(Kriteria Diagnosis)

Daftar Masalah Permanen

Diagnosis

Interpretasi data abnormal

Cost-Benefit Analysis

Rencana Awal :

Dx

Mx

Tx

Ex

Catatan KemajuanMasalah 1 S O A P : Dx Mx Tx ExMasalah 2Masalah n

P.O.M.R

BASE LINE DATA

CLUE AND CUE

PROBLEM LIST / DIAGNOSISPLANNING

Dx Tx Edu.

1.2.3.4.5.

1.Problem 2.problem3.Diagnosis 4. Problem

SUBJECTIVE OBJECTIVE ASSESMENT PLANNING

Dx Tx Edu

FOLLOW UP

Naïve Patient Management

• Primary surveyo Emergency caseo Urgency caseo A, B, Co stabilization

• Secondary surveyo Data findingo Confirm diagnoseo Treatment

Summary

The clinical process in an implementation of scientific method to resolve clinical problem

Consist of: Scientific problem solving approach Decision making (in diagnosis & therapeutic process)

Diagnosis is an abstraction of disease They need diagnosis criteria (based on sign &

symptoms) No tools of diagnosis has 100% specificity &

sensitivity Think about probability in diagnosis & treatment

Integration of Clinical Data and Suporting Test

Anamnesa Physical Exam Test Result

Nominal DataOrdinal Data Metrics Data

- clinical knowledge base- experience base

Problem / Diagnose

Problem Solving Approach in Clinical Setting

1. Scientific Problem Solving Approach

2. Decision Making