Chapter 3: Application of Models for Organization and Guidelines for Content

INTRODUCTION

RECORD FORMATS

A variety of record formats are used by physical therapists (PTs). Categorically, they include source-oriented, problem-oriented, and integrated systems.

The source-oriented medical record keeping (SOMR) system has been commonly used in hospitals and skilled nursing facilities for decades. Each record, or “chart,” is divided into sections by profession or service given (i.e., physical therapy, nursing, medical, physician orders, laboratory, etc.). Patient problems are not separated and notes between caregivers are not integrated because they are “parallel” in nature. Entries in each section are usually in chronological order. It may be time consuming for the PT to glean patient information from the SOMR because of this structure. Additionally, within each section, the methodology for recording information may be different for each discipline, but each discipline should be consistent with itself. This record keeping allows for easy access by a service group provider, but makes it difficult for overall assessment of the patient.

A component of the problem-oriented medical record (POMR) system, the SOAP (subjective, objective, assessment/analysis, plan) or SOAPIER (SOAP implementation of plan, evaluation of the implemented plan, and revision of the plan if necessary) note, has been commonly used by PTs, but less so with the advent of electronic medical records (EMRs). Common use, however, should not be misunderstood to translate to the best or most effective or efficient method for every situation. In an effort to improve patient record keeping, in 1958 Dr. Lawrence Weed of the University of Vermont began exploring alternative types of record entries. The POMR, developed in 1969, focuses on a patient’s specific problems in an integrated and coordinated manner between professionals.^1,2 Weed’s system includes the initial assessment, problem list, initial plan, progress notes, and discharge summary. All patient problems are included and numbered, active (current) and past, and all professionals involved in the patient’s care contribute to the list. In the “pure” system, only one problem can be addressed on a SOAP progress note. Physician orders, not included in the initial plan, are cross-coded for relevance by number to the problems identified. Notes in the POMR are recorded in the SOAP or SOAPIER format. Dr. Weed offered categories to assist professionals in clarifying information.^1,2