Teori POMR

8/17/2019 Teori POMR

1/23

PROSES KLINIKdan POMR

dr. Meddy Setiawan, SpPD

Internal Medicine DepartmentUniversity o M!"ammadiya"

Malan#


2/23

RE$EREN%ES&RE$EREN%ES&

Harrison’s Principles of

Internal Medicine, 17th Edition

Delph & Manning :

Physical Diagnosis


3/23

Proses Klinik Merpakan proses penga!"ilan

keptsan pada penderita

Mlai : peng!plan data sa!paikesi!plan

Mlai : kelhan ta!a sa!pai D#

dan $# Meli"atkan interaksi dokter %

penderita


4/23

DO%'OR P('IEN'SDO%'OR P('IEN'S

REL('IONS)IPREL('IONS)IP

Patient

Doctor

Doctor

environment

%!lt!re

*elie

Reli#ion

Ed!cation

Privacy

%!lt!re

Reli#ion

*elie

Ed!cation

Privacy

personality


5/23

PRO*LEM (N(L+SISPRO*LEM (N(L+SIS

P$IE'$’( P)*+EM(

-.$.)E

*$HE)(

(PI)I$.)EI$IE(

PH/(I-

(*-I


6/23

S%IEN'I$I% PRO*LEMS SOLIN-S%IEN'I$I% PRO*LEMS SOLIN-

(PPRO(%)(PPRO(%)S.P.S.A.

PROBLEM IDENTIFICATION

EVALUATION DATA COLLECTION

IMPLEMENTATION DATA ANALYSIS

PRIORITY SETTING HYPOTHESIS

FORMULATION

PROBLEM SOLVING HYPOTHESIS

ALTERNATIVE TESTING

CLINICAL PROCESS

HEALTH PROBLEM

FOLLOW-UP ANAMNESA/ P.D./

LAB. / MED-RECORD

IMPLEMENTATION DATAS &

INFORMATION

ANALYSIS

TREATMENT DIAGNOSIS

PRIORITY SETTING SYNTHESIS

TREATMENT DIAGNOSIS

ALTERNATIVES PLANNING


7/23

Pendidikan dokter !engala!i per"ahan!endasar dala! krn 0akt tahn :(PI-E( (tdent centered Pro"le! "ased

Integrated -o!!nity "ased Early e#posre to clinic (trctred

Mengac standart pendidikan profesi danko!petensi Per"ahan "esar pada krkl! 2 K+K

dengan pendekatan P+


8/23

ROLES O$ DO%'OR

-linical e#pert

Health ad3ocate

Manager $ea! player

(cholar and teacher

Professional


9/23

(kenario P)EKI'IK r!i 45 th datang ke .6D

dengan kelhan sesak nafas yang

!akin la!a !akin "erat (esaktelah dirasakan se8ak 1 !inggyang lal r!i adalah seorang

i" !da dengan keha!ilan 5"lan pa yang !ngkin ter8adipada r!i 9


10/23

(kenario KI'IK % P*M) r!i 45 th datang ke .6D dengan kelhan sesaknafas yang !akin la!a !akin "erat (esak dirasakanse8ak 1 !ingg yang lal r!i adalah i" !dadengan keha!ilan 5 "lan (elain it r!i 8ga

!engelhkan se!"a" pada tngkai se8ak "lan yanglal Pe!eriksaan ;sik $ 15


11/23

POMR?Pro"le! *riented Medical

)ecord@


12/23

P*M) : (!!ary of data "ase ?#, Physical

E#a!ination, a"oratory@

-le and ce P)*+EM I($ Initial diagnosis ?diferential diagnosis@

Planing : Diagnosis, $herapy Monitor, Edcation


13/23

Aor!at P*M)SUMMARYof

DATA BASE

CLUEandCUE

PROBLEMLIST

INITIALDX

PLANNING

DIAGNO

SIS

THERAPY MONITOR

ING

EDUCA

TION

Identity :

Chief

o!"#aint :

Ana!ne$e :

Phy$ia#e%a!ination

:

La&o'ato'yfindin( :


14/23

Pertanyaan : +agai!ana !eng!plkan data 9

+agai!ana !e!"at data groping 9

+agai!ana !e!"at Bpro"le!C 9

+agai!ana !e!"at initialdiagnosa 9

+agai!ana !e!"at rencana D#, $#,Mo, Ed 9


15/23

History taking

Physical e#a!ination dditional e#a!ination :

a"oratory e#a!ination

2 ray e#a!ination I!aging ? .(6, Doppler, etc @

)ow do we collect t"e

data


16/23

Data Pro/lem

Data%

Data%+

Data%-

Data%D

Data%E

Data%A

Data%6Data%H

Data%I

Data%

Pro"le!%1

Pro"le!%4

Pro"le!%

Pro"le!%F


17/23

Data , +, E and I Pro"le!%1

Data D and H Pro"le!%4 Data , - and E Pro"le!%

Data A, 6 and Pro"le!%F


18/23

Data groping is "ased on the

diagnostic criteria

Data #ro!pin# 0 pro/lem c!e and

cl!e 1


19/23

Pro"le! is synthesiGed fro! the data and "ased ondiagnosis criteria

Pro"le! is fact not sspect Pro"le! can "e :

a. Dia#nosis ? if the data has fl;ll the diagnosiscriteria @

/. Syndromes ? if the data has not fl;ll the

diagnosis criteria, "t fl;ll the criteria ofsyndro!es @

c. Si#n or symptoms ? if the data has not fl;ll thediagnosis criteria and the criteria of syndro!es,"t 8st only fond as sign or sy!pto!

Pro"le! !st "e n!"ered ? 1 , 4 , etc @

'o ma2e t"e pro/lem


20/23

E3ample

Ae!ale > yo ?far!er@, ad!itted 0ithchief co!plain shortness of "reathsince 4 !onth ago co!e and go

especially in acti3ity Prodcti3ecogh 0ith yello0ish spt! Ae3ernoted 7 days aco!pained "y decrease

of appetite, "loating and nasea (hestayed in cro0ded area 0ith children


21/23

P"isical E3amination

ook se3ere ill, -M, +MI 1 Kg=!4,+P 1


22/23

La/oratory 4ndin#

H" ,5 gr=

ecocyt 14


23/23

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