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- chief complaint
- what they state verbally is bothering them
- reason why they came to see dr.
- (ex. cold, runny nose)
- observed during physical
- vital signs
- lab results
- (ex. tenderness, wheezing, etc.)
- diagnoses (may be more than one)
- organized by problem presented or organ system
- (ex. appendectomy)
- treatment, med./surg. procedure, referrals, followup drug work, drugs, etc.
- (ex. blood test, referral to psychiatrist)
problem oriented medical record
- POMR Rx
- 1. hypertension AdalatXL30mg
2. prediabetes diet + exercise
3. menopause DEXA