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Inpatient Use of the Problem-Oriented Medical Records in Urology
Vol. 110_ Noven1ber Printed [IS.A.
OF UROLOGY
CopyrigL-::: © J 973 hy Th2 V/illia~~s
"\i\7ilkins
INPATIENT USE OF THE PROBLEM-ORIENTED MEDICAL RECORDS IN UROLOGY HARRY J. CAMPBELL
AND
J. FENIMORE COOPER
From the Department of Urology, Southern California Permanente Medical Group and Kaiser Foundation Hospital, Los Angeles, California
The Problem-Oriented Medical Record (POMR) has found increasing usage in training centers throughout the nation in recent years and Weed's concepts have not left urological programs untouched.'· 2 Barry has described the use of a problem-oriented flow sheet for outpatients. 3 Herein is described the use of the problem-oriented medical record system for inpatients in a urological residency training program. DESCRIPTION OF THE POMR SYSTEM
The purpose of the POMR is to facilitate communication among physicians regarding patient care by assigning a number and title to each patient's medical or surgical problems. The physicians caring for the patient then resolve each problem as best they can during the hospitalization. At the Kaiser Foundation Iv1edical where 6 full-time staff urologists work closely with 6 the POMR is carried out in the following manner. The resident first interviews and examines a patient for hospitalization, completing a standard history and physical examination form. Admission laboratory tests and x-rays are obtained and the patient's previous clinic and hospital charts are reviewed. The resident then constmcts a problem list, including all specific diagnoses, abnormal findings on physical examination, abnormal and unexplained laboratory tests, unusual social situations, allergies and warnings to those who will be caring for the patient. The problem list then becomes the first page of the medical record. Each problem is assigned a specific number, which is henceforth carried with the patient's record, hospitalization.
are classified accordobservations, treattions, an Assessment of the ment Plan (SOAP). consultation reports are 1n a for publication l\ilay 18, 197:3. L. L.: Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record as a Basic Tool. Cleveland: The Press of Case Western Reserve University, 1969. 2 Weed, L. L.: Medical records that guide and teach. New Engl. J. Med., 278: 593, 1968. 3 Barry, J. M., Palken, M. and Hodges, C. V.: Flow sheets and care of the urology clinic patient. J. Urol., 108: 785, 1972. 579
standard manner, listing the problem for which the patient is being consulted, the impression, the recommendations for further evaluation or treatment and comments by the urologic consultant. The urologist may expand his thoughts about the case in a narrative style under comments. Discharge summaries follow a consistent format. The problem that necessitated hospitalization is listed first, with its assigned number, followed by each important problem noted during that hospitalization with its appropriate number. Since all operative procedures are considered problems, they are listed as well. Under each problem heading, the resident dictates a brief narrative, describing the important facets of that particular problem along with its treatment and disposition. MOCK EXAMPLE OF HOW THE SYSTEM WORKS
An internist sent a patient to the Department with consultation request: "This is a 64-year-old man with diabetes mellitus. I think I feel an enlarged prostate. He also complains of nocturia and urinary hesitancy. Please evaluate." After having interviewed and examined the patient, the resident checked with the staff urologist about the evaluation. The resident then completed the consultation request (table 1). After suitable preparation the patient returned for an excretory urogram (IVP), which showed good function bilaterally and indirect evidence of prostatic enlargement. The resident then completed the necessary evaluation for admission to the hospital, including the chief complaint, present illness and past as well as family history. The clinic nurse had taken his vital signs and had already written them on the physical examination form for the resident. The resident reviewed the patient's old clinic chart to make sure was missed. The report of the chest x-ray done 2 weeks earlier was so it was not re-ordered. Since the patient had not had a recent one was ordered, as was a and After having completed the data the resident filled out the patient's problem list, including all items pertaining to the past and present illnesses and social situation. The resident organized the problems according to his estimation of priorities (table 2). The patient was then admitted to the hospital. The problem list was included as the first page of the chart. The internist referred to the problem list that evening when he visited the patient. He wrote
580
CAMPBELL AND COOPER
a progress note in the chart, using the POMR system (table 3). The next morning the patient was taken to the operating room and was given a general anesthesia for cystoscopy and prostatic needle biopsies, which were performed without difficulty. A lSF Foley catheter was left in the bladder and the patient was taken to the recovery room. After having written a brief operative report in the chart, the resident checked the patient later in the day and then described his findings (table 4). Note that the resident assigned a new number to the operative procedure (5 Cysto/PNB). Subsequent progress notes referable to the operation would continue to carry the number and title ascribed to it. The resident also added this procedure to the problem list.Note that the resident had not written a progress note about the patient's inactive pulmonary tuberculosis or the tonsillectomy, since these problems were inactive and did not pertain to the current hospitalization. By the first postoperative day the biopsy report became available, demonstrating "nodular benign TABLE 1
Problem-enlarged prostate with prostatism Impression-approximately 30 gm. nodular prostate Recommendations-IVP tomorrow; cystoscopy and prostatic needle biopsy in 2 days Comment-this patient gives a history of pulmonary tuberculosis. He claims he had a recent chest x-ray, the report of which is not available at this time. Although it would be rare, prostatic tuberculosis is possible, so I will obtain needle biopsy specimens for acid-fast culture and histologic studies On rectal examination the prostate is enlarged with some nodularity of the left lobe. If this were to turn out to be adenocarcinoma by biopsy, I would consider this to be stage 2, B. Since I have done a rectal examination on him today, I will defer for a week in obtaining a serum acid phosphatase determination
1) Enlarged, nodular prostate S-prostatism 0-trilobar hypertrophy with mild trabeculation was noted at cystoscopy A-same P-await biopsy report 5) Cysto/PNB S-tolerates catheter without much discomfort 0-urine practically clear; afebrile A-normal postop. course P-will discontinue catheter in morning if urine is clear
R. Urologist, M. D. 12-8-72
TABLE
5
1) Enlarged, nodular prostate S-none 0-biopsy reports "benign nodular hyperplasia" only; there is no evidence of carcinoma A-benign hyperplasia P-will discuss transurethral resection of prostate with patient 5) Cysto/PNB S-no complaints 0-urine clear, afebrile, on sulfisoxazole A-doing well P-discontinue catheter today
R. Urologist, M. D. 12-9-72
TABLE
6
12-4-72
X
1952
X
R. Urologist, M. D.
TABLE
1) Enlarged, nodular prostate 2) Diabetes mellitus, adult onset 3) Pulmonary tuberculosis 4) Tonsillectomy
4
Admitted-12-7-72 Discharged-12-9-72 Patient profile-64-year-old married man Problem 1-benign nodular prostatic hyperplasia, 12-8-72. Patient was hospitalized for evaluation of nodular prostate. Cystoscopy showed obstructive gland and prostatic needle biopsy showed only benign hyperplasia. Patient is scheduled for transurethral resection in 3 weeks Problem 5-cystoscopy and prostatic needle biopsy, 12-8-72. Patient tolerated procedure well. Foley catheter was removed on first postoperative day and urine was clear. He was discharged on sulfisoxazole, 1 gm., 4 times a day. He will be seen in urology clinic in 1 week Problem 2-diabetes mellitus, adult onset, which posed no difficulty on this hospitalization. Dr. Internist will see patient in 1 week as well Problem 3-pulmonary tuberculosis, inactive, 1926 Problem 4-tonsillectomy, 1935
Resident Urologist, M. D./Staff Urologist, M. D. 12-6-72
Problem
TABLE
Date Detected
2 Date Resolved
Active Inactive
1917
1926
X
1935
1935
X
TABLE
3
2) Diabetes mellitus S-none 0-no glycosuria on admission urinalysis A-adult onset, mild, under control P-1,800-calorie diabetic diet postoperatively T. Internist, M. D. 12-7-72
prostatic hyperplasia". The resident recorded the progress notes (table 5). After the resident and staff urologist discussed the patient's condition with him that day, it was decided to discharge the patient and to have him scheduled for a transurethral resection of the prostate gland within 3 weeks. The resident dictated a discharge summary (table 6). The resident did not have to dictate a narrative under the patient's inactive problems (3 and 4) but since the patient had never been hospitalized at Kaiser Foundation Medical Center before, he
INPAT!ENT USE OF PROBLEM-ORIENTED MEDICAL RECORDS IN i.JROLOGY
thought i: best to list the resolved problems anyway for completeness. GENERAL COMMENTS
With the POMR it became much easier for the urologists to chronologically follow the ailments of each hospitalized patient. Consultants to the urologic service have been saved much effort and time formerly invested in reviewing the patients' old clinic and hospital charts by the improved and systematic organization of the medical record. Followup visits in the clinic were also facilitated, since the discharge summaries were better organized and information contained in them was easier to locate in comparison to former methods of dictating discharge summaries. The attending staff generally found it easier to evaluate the resident's care of his patients, since his orders and treatment could be related directly to the resident's assessment of each problem. PHYSICIAN ACCEPTANCE
The POMR was introduced to us m 1972 and from that time on each urologist, staff or resident was required to write progress notes, doctors' orders, discharge summaries and consultations in the standardized manner of the POMR. Initially, there was reluctance on the part of some of the physicians but, after a brief transition period of 4 to 6 weeks, all physicians complied with the requiremenL Technical difficulties were handled as they arose by a trouble-shooting staff composed of an attending physician and 2 residents who regularly and carefully monitored the urologic data recorded by the participants. An anonymous survey was made 3 months after the syst~m was started. Questions regarding specific parts of the system were asked as well as questions pertaining to its acceptance and value. The results of the questionnaire disclosed that the physician 1) considered it helpful and important
581
that the problem list be kept up to date, 2) thought that the discharge summaries were easier to dictate using the POMR system than the old waythe dictation time seemed to be less than previ0c1sly and 3) found that the time taken to write progress notes was about the same with the new system as with the old but that the data recorded were more pertinent and succinct. DISCUSSION
The classic interpretation of the POMR insists that a well defined data base be established and followed. In strict terms, this implies that for each patient seen in the urology clinic for evaluation, the nursing staff should collect a prescribed set of data, such as blood pressure, temperature, urine specimen for urinalysis and culture, and that the examining physician should perform a specific set of examinations, such as careful palpation of the abdomen, inspection and palpation of the genitalia and prostate and microscopic examination of the urine. We agree with Goldfinger that such rigidity may discourage the physician from exercising his judgment and may diminish his creativity. 4 Consequently, we have minimized the data base for physicians, allowing them a greater flexibility in handling their patients. The residents and staff urologists have found this to be a rewarding arrangement. A major factor in aiding the development of the POMR system at our center is the full-time status of the staff urologists. It permits them to conveniently conduct a daily audit of the residents' medical care as demonstrated in the POMR. We recommend use of POMR in other urological training centers. • Goldfinger, S. E.: The problem-oriented record: a critique from a believer. New Engl. J. Med., 288: 606, 1973.
OF UROLOGY
CopyrigL-::: © J 973 hy Th2 V/illia~~s
"\i\7ilkins
INPATIENT USE OF THE PROBLEM-ORIENTED MEDICAL RECORDS IN UROLOGY HARRY J. CAMPBELL
AND
J. FENIMORE COOPER
From the Department of Urology, Southern California Permanente Medical Group and Kaiser Foundation Hospital, Los Angeles, California
The Problem-Oriented Medical Record (POMR) has found increasing usage in training centers throughout the nation in recent years and Weed's concepts have not left urological programs untouched.'· 2 Barry has described the use of a problem-oriented flow sheet for outpatients. 3 Herein is described the use of the problem-oriented medical record system for inpatients in a urological residency training program. DESCRIPTION OF THE POMR SYSTEM
The purpose of the POMR is to facilitate communication among physicians regarding patient care by assigning a number and title to each patient's medical or surgical problems. The physicians caring for the patient then resolve each problem as best they can during the hospitalization. At the Kaiser Foundation Iv1edical where 6 full-time staff urologists work closely with 6 the POMR is carried out in the following manner. The resident first interviews and examines a patient for hospitalization, completing a standard history and physical examination form. Admission laboratory tests and x-rays are obtained and the patient's previous clinic and hospital charts are reviewed. The resident then constmcts a problem list, including all specific diagnoses, abnormal findings on physical examination, abnormal and unexplained laboratory tests, unusual social situations, allergies and warnings to those who will be caring for the patient. The problem list then becomes the first page of the medical record. Each problem is assigned a specific number, which is henceforth carried with the patient's record, hospitalization.
are classified accordobservations, treattions, an Assessment of the ment Plan (SOAP). consultation reports are 1n a for publication l\ilay 18, 197:3. L. L.: Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record as a Basic Tool. Cleveland: The Press of Case Western Reserve University, 1969. 2 Weed, L. L.: Medical records that guide and teach. New Engl. J. Med., 278: 593, 1968. 3 Barry, J. M., Palken, M. and Hodges, C. V.: Flow sheets and care of the urology clinic patient. J. Urol., 108: 785, 1972. 579
standard manner, listing the problem for which the patient is being consulted, the impression, the recommendations for further evaluation or treatment and comments by the urologic consultant. The urologist may expand his thoughts about the case in a narrative style under comments. Discharge summaries follow a consistent format. The problem that necessitated hospitalization is listed first, with its assigned number, followed by each important problem noted during that hospitalization with its appropriate number. Since all operative procedures are considered problems, they are listed as well. Under each problem heading, the resident dictates a brief narrative, describing the important facets of that particular problem along with its treatment and disposition. MOCK EXAMPLE OF HOW THE SYSTEM WORKS
An internist sent a patient to the Department with consultation request: "This is a 64-year-old man with diabetes mellitus. I think I feel an enlarged prostate. He also complains of nocturia and urinary hesitancy. Please evaluate." After having interviewed and examined the patient, the resident checked with the staff urologist about the evaluation. The resident then completed the consultation request (table 1). After suitable preparation the patient returned for an excretory urogram (IVP), which showed good function bilaterally and indirect evidence of prostatic enlargement. The resident then completed the necessary evaluation for admission to the hospital, including the chief complaint, present illness and past as well as family history. The clinic nurse had taken his vital signs and had already written them on the physical examination form for the resident. The resident reviewed the patient's old clinic chart to make sure was missed. The report of the chest x-ray done 2 weeks earlier was so it was not re-ordered. Since the patient had not had a recent one was ordered, as was a and After having completed the data the resident filled out the patient's problem list, including all items pertaining to the past and present illnesses and social situation. The resident organized the problems according to his estimation of priorities (table 2). The patient was then admitted to the hospital. The problem list was included as the first page of the chart. The internist referred to the problem list that evening when he visited the patient. He wrote
580
CAMPBELL AND COOPER
a progress note in the chart, using the POMR system (table 3). The next morning the patient was taken to the operating room and was given a general anesthesia for cystoscopy and prostatic needle biopsies, which were performed without difficulty. A lSF Foley catheter was left in the bladder and the patient was taken to the recovery room. After having written a brief operative report in the chart, the resident checked the patient later in the day and then described his findings (table 4). Note that the resident assigned a new number to the operative procedure (5 Cysto/PNB). Subsequent progress notes referable to the operation would continue to carry the number and title ascribed to it. The resident also added this procedure to the problem list.Note that the resident had not written a progress note about the patient's inactive pulmonary tuberculosis or the tonsillectomy, since these problems were inactive and did not pertain to the current hospitalization. By the first postoperative day the biopsy report became available, demonstrating "nodular benign TABLE 1
Problem-enlarged prostate with prostatism Impression-approximately 30 gm. nodular prostate Recommendations-IVP tomorrow; cystoscopy and prostatic needle biopsy in 2 days Comment-this patient gives a history of pulmonary tuberculosis. He claims he had a recent chest x-ray, the report of which is not available at this time. Although it would be rare, prostatic tuberculosis is possible, so I will obtain needle biopsy specimens for acid-fast culture and histologic studies On rectal examination the prostate is enlarged with some nodularity of the left lobe. If this were to turn out to be adenocarcinoma by biopsy, I would consider this to be stage 2, B. Since I have done a rectal examination on him today, I will defer for a week in obtaining a serum acid phosphatase determination
1) Enlarged, nodular prostate S-prostatism 0-trilobar hypertrophy with mild trabeculation was noted at cystoscopy A-same P-await biopsy report 5) Cysto/PNB S-tolerates catheter without much discomfort 0-urine practically clear; afebrile A-normal postop. course P-will discontinue catheter in morning if urine is clear
R. Urologist, M. D. 12-8-72
TABLE
5
1) Enlarged, nodular prostate S-none 0-biopsy reports "benign nodular hyperplasia" only; there is no evidence of carcinoma A-benign hyperplasia P-will discuss transurethral resection of prostate with patient 5) Cysto/PNB S-no complaints 0-urine clear, afebrile, on sulfisoxazole A-doing well P-discontinue catheter today
R. Urologist, M. D. 12-9-72
TABLE
6
12-4-72
X
1952
X
R. Urologist, M. D.
TABLE
1) Enlarged, nodular prostate 2) Diabetes mellitus, adult onset 3) Pulmonary tuberculosis 4) Tonsillectomy
4
Admitted-12-7-72 Discharged-12-9-72 Patient profile-64-year-old married man Problem 1-benign nodular prostatic hyperplasia, 12-8-72. Patient was hospitalized for evaluation of nodular prostate. Cystoscopy showed obstructive gland and prostatic needle biopsy showed only benign hyperplasia. Patient is scheduled for transurethral resection in 3 weeks Problem 5-cystoscopy and prostatic needle biopsy, 12-8-72. Patient tolerated procedure well. Foley catheter was removed on first postoperative day and urine was clear. He was discharged on sulfisoxazole, 1 gm., 4 times a day. He will be seen in urology clinic in 1 week Problem 2-diabetes mellitus, adult onset, which posed no difficulty on this hospitalization. Dr. Internist will see patient in 1 week as well Problem 3-pulmonary tuberculosis, inactive, 1926 Problem 4-tonsillectomy, 1935
Resident Urologist, M. D./Staff Urologist, M. D. 12-6-72
Problem
TABLE
Date Detected
2 Date Resolved
Active Inactive
1917
1926
X
1935
1935
X
TABLE
3
2) Diabetes mellitus S-none 0-no glycosuria on admission urinalysis A-adult onset, mild, under control P-1,800-calorie diabetic diet postoperatively T. Internist, M. D. 12-7-72
prostatic hyperplasia". The resident recorded the progress notes (table 5). After the resident and staff urologist discussed the patient's condition with him that day, it was decided to discharge the patient and to have him scheduled for a transurethral resection of the prostate gland within 3 weeks. The resident dictated a discharge summary (table 6). The resident did not have to dictate a narrative under the patient's inactive problems (3 and 4) but since the patient had never been hospitalized at Kaiser Foundation Medical Center before, he
INPAT!ENT USE OF PROBLEM-ORIENTED MEDICAL RECORDS IN i.JROLOGY
thought i: best to list the resolved problems anyway for completeness. GENERAL COMMENTS
With the POMR it became much easier for the urologists to chronologically follow the ailments of each hospitalized patient. Consultants to the urologic service have been saved much effort and time formerly invested in reviewing the patients' old clinic and hospital charts by the improved and systematic organization of the medical record. Followup visits in the clinic were also facilitated, since the discharge summaries were better organized and information contained in them was easier to locate in comparison to former methods of dictating discharge summaries. The attending staff generally found it easier to evaluate the resident's care of his patients, since his orders and treatment could be related directly to the resident's assessment of each problem. PHYSICIAN ACCEPTANCE
The POMR was introduced to us m 1972 and from that time on each urologist, staff or resident was required to write progress notes, doctors' orders, discharge summaries and consultations in the standardized manner of the POMR. Initially, there was reluctance on the part of some of the physicians but, after a brief transition period of 4 to 6 weeks, all physicians complied with the requiremenL Technical difficulties were handled as they arose by a trouble-shooting staff composed of an attending physician and 2 residents who regularly and carefully monitored the urologic data recorded by the participants. An anonymous survey was made 3 months after the syst~m was started. Questions regarding specific parts of the system were asked as well as questions pertaining to its acceptance and value. The results of the questionnaire disclosed that the physician 1) considered it helpful and important
581
that the problem list be kept up to date, 2) thought that the discharge summaries were easier to dictate using the POMR system than the old waythe dictation time seemed to be less than previ0c1sly and 3) found that the time taken to write progress notes was about the same with the new system as with the old but that the data recorded were more pertinent and succinct. DISCUSSION
The classic interpretation of the POMR insists that a well defined data base be established and followed. In strict terms, this implies that for each patient seen in the urology clinic for evaluation, the nursing staff should collect a prescribed set of data, such as blood pressure, temperature, urine specimen for urinalysis and culture, and that the examining physician should perform a specific set of examinations, such as careful palpation of the abdomen, inspection and palpation of the genitalia and prostate and microscopic examination of the urine. We agree with Goldfinger that such rigidity may discourage the physician from exercising his judgment and may diminish his creativity. 4 Consequently, we have minimized the data base for physicians, allowing them a greater flexibility in handling their patients. The residents and staff urologists have found this to be a rewarding arrangement. A major factor in aiding the development of the POMR system at our center is the full-time status of the staff urologists. It permits them to conveniently conduct a daily audit of the residents' medical care as demonstrated in the POMR. We recommend use of POMR in other urological training centers. • Goldfinger, S. E.: The problem-oriented record: a critique from a believer. New Engl. J. Med., 288: 606, 1973.