The Problem Oriented Medical Record (POMR) and SOAP

POMR
The POMR was developed by a physician in 1964 as a way to record all relevant patient data
in an organized manner.

The first step to recording a patients medical data, whether it is organized in a POMR or
SOAP, is to introduce yourself and to verify the patients identity (ID).

- Make sure you establish your title (e.g. student pharmacist)
- Collect the persons name, date of birth, gender, and race

The next step is to collect the patients chief complaint (CC). The chief complaint is the
patients reason for visiting or seeking counsel. Follow-up questions asked after this step will
lead to collecting information for the next set of information.

After collecting the CC, the patients history of present illness (HPI) should be collected.
Examples of questions to ask include:
- What medications have you used to treat this condition?
- How long have you been experiencing this?
- Can you give me more descriptions about the symptoms?
- How has your diet or environment changed?
- How severe is this pain on a scale of 1 to 10?

If the patient has not been worked up yet, it is important to collect his or her past medical
history (PMH), past surgical history (PSH), family history (FH), social history (SH),
allergies, and medication history.

The PMH is a description or listing of their conditions or illnesses in the past.

The PSH is a description or listing of the surgeries the patient has undergone prior to the
encounter.

The FH is information regarding pertinent medical history of family members. Typically,
information about parents and grandparents should be collected. Also, diseases and
abnormalities, which are typically passed down genetically should be collected.

The patients social history (SH) should also be collected. SH includes:
- Diet (Fats? Salt intake? Caffeine? Fiber? Alcohol? Greens?)
- Lifestyle (Exercise? Occupation? Sedentary? Frequent travel? Frequent naps? Lack
of sleep? Sleep apnea?)
- Habits (Tobacco? Recreational drug use?)
- Living situation and support systems
- Health prevention

When collecting information on a patients allergies, include drug allergies, food allergies, and
chemical (e.g. latex, dye) allergies. Intolerances and major side effects need to be included as
well.

The patients medication history should also be gathered. The following elements of each
medication should be noted:
- Prescription, OTC, and dietary supplements
- Name, strength, dose, route, and frequency
- Indication for each medicine (may be in the HPI or PMH)
- Compliance
- Perceived effects
- Duration

The Review of Systems (ROS) is a subset of the physical examination (PE) which reviews the
following organs and organ systems:
- HEENT (Head, Eyes, Ears, Nose, Throat)
- GI (gastrointestinal/ stomach area)
- Lungs
- Cardiovascular system
- Extremities (legs, feet, skin, nails)
- Bowels

The PE is usually completed by a medical doctor or nurse practitioner. However, Pharm. D.s
can perform superficial PE elements.

Labs include laboratory data and results of other tests, including:
- Blood pressure (normal BP is 120/80 mmHg, or under)
- Heart rate (normal HR is 60-80 bpm)
- Temperature (normal T is 37C or 98.6 F)
- Weight and height

A patient should have a problem list, which is a complete list of problems (active and
inactive), their date of onset and resolution.

Each problem on the problem list needs a problem number, a problem title, the date of
problem onset, and the date of problem resolution.

The most immediate problems (commonly the CC) should be on the beginning of the list.
Resolved or stabilized problems should be towards the end of the list. It is important to keep
problems on the list, even if they are resolved.

Each problem is summarized by what is known, current treatment, and assessment of
recommendations for change.

Examples of problems on a problem list:
- Definitive diagnoses (e.g. hypertension, hyperlipidemia)
- Physiological finding (e.g. heart failure, and etiology)
- Symptom or finding
- Abnormal value, scan, or x-ray
- Patient concerns (e.g. ability to pay for medications, addictive behavior)





SOAP
SOAP stands for subjective, objective, assessment, and plan. The chief complaint should be
SOAPed. It is important that the subjective and objective data collected should be specific to
the chief complaint.

Subjective: Descriptive data about how the patient feels or any qualitative observations about
the patient

Objective: Test results, procedures and assessments, vital signs, findings on physical exam. If
other health care providers repeat the same test or procedure under similar conditions and
obtain similar results, the data is objective.

Assess three components:
(1) Etiology and risk factors ! What is the primary reason for the problem, and what
risk factors may contribute to the problem? Rank the conditions based on which is
the likely etiology for the problem.
a. Disease
b. Drugs
c. Diet
d. Lifestyle
e. Social and family history
(2) Assess Need for Therapy ! Should the patient be referred to an M.D.? Should we
watch and wait? Are there any OTCs or lifestyle modifications that could help
remedy the problem?
(3) Assess Current Therapy, Therapy Options and Drugs to Avoid
a. Current Therapy: Should it be continued? How can it be optimized?
b. Therapy Options: What options are out there? What are the advantages or
disadvantages? Which is best, based on the patients situation?
c. Drugs to Avoid: What should the patient avoid while taking therapy options?

Plan (six components)
(1) Recommended Therapy
a. Enact a plan for current therapy and if discontinued, give reasons
b. Enact a plan for recommended therapy where dosing is patient specific
a. PK, organ function should be taken into account. Provide the drug, dose,
route, schedule, duration
(2) List of drugs to avoid/ reason
(3) Future tests/ Plans
(4) Goals
(5) Monitoring parameters
a. Disease specific and drug specific parameters
(6) Patient education
a. Educate patient on disease
b. Educate patient on the drug therapy, and what drugs to avoid
c. Counsel on drug use, side effects, storage
d. Follow-up plans
e. Lifestyle
f. Non-drug recommendations
g. Contact information for questions