POMR and SOAP Notes

The Problem Orientated Medical Record
(POMR) and SOAP Note
Prepared and presented by

Marc Imhotep Cray, M.D.
The Problem Orientated
Medical Record (POMR)
2
Problem Orientated Medical Record
(POMR) Defined
 The POMR as initially defined by Lawrence Weed, MD, is the official
method of record keeping use by most medical centers and thus in
most undergraduate medical schools
 The SOAP note originates from the POMR
 SOAP is an acronym for Subjective, Objective, Assessment, and Plan
 POMR preserves data in an easily accessible way that encourages

ongoing assessment and revision of health care plan by all members of
health care team
 Proper use results in concise, complete and accurate record keeping
Marc Imhotep Cray, M.D. 3

Basic components of POMR & SOAP Note
 5 components of the POMR are:
1. Data Base-History, Physical Exam and Laboratory Data
2. Complete Problem List
3. Initial Plans
4. Daily Progress Note
5. Final Progress Note or Discharge Summary
Again, SOAP note originates from POMR
 4 Components of the SOAP Note
1. Subjective=Medical History
2. Objective=Physical Examination & Laboratory / Diagnostic Investigations
3. Assessment=Problems/ Initial Impression(Hypotheses /DDx)
4. Plan= Diagnostic work up and Therapeutic management
 A plan is only as good as the diagnostic hypotheses that generated it
1. Data Base
 A data-base is collected before beginning process of identifying
patient's problems
 Data Base must include a complete history and physical exam

 Many hospitals include certain routine laboratory studies
(CBC, SMAC, EKG, chest x-ray, urinalysis, etc.) for each
patient admitted
o If these are available to admitting physician, they are to be
included in initial data base along with a history and physical
o As additional information is collected it is added to Data Base

2. Complete Problem List
 After preforming the medical history and physical exam and reviewing
basic laboratory data and records (the data base) the Problem List is
constructed and recorded
 Construction of a Problem List is the initial step of what physicians

"really do“
 That is, once they have seen the patient, physicians think about and
define
o "what is wrong with the patient" or
o "what are this patient's problems"

Complete Problem List (2)
 A problem is defined as anything that causes concern to patient
or to caregiver, including:
 physical abnormalities
 psychological disturbance, and
 socioeconomic problems
 List serves as an index to rest of record & is arranged in 4 or 5 columns:
1. a chronologic list of problems
2. date of each problem's onset
3. action taken
4. outcome (often its resolution), and
5. date of outcome
 Problems are either active or inactive  inactive problems are
usually prior, resolved medical or surgical illnesses that are still
important to be remembered
 Dr. Weed had defined an active problem as anything that requires
management or further diagnostic workup
 Physicians often get caught up in defining Problems and Problem

Lists, accusing each other of lumping, splitting, etc.
 This is unnecessary (see next slide for rational)

Important facts to be noted in constructing a problem list are these:
A. A problem should be defined at its highest level of defensibility
For example:
 Beginning medicine clerk (medical student) admits a patient with vomiting and confusion
 On physical exam patient is found to have muscle twitching and a pericardial friction rub
 The initial lab data reveals a BUN of 100 and potassium of 7.0 (both elevated)
 The student lists each of these abnormalities as a separate problem

• This listing of six problems tells us that beginning student does not recognize that all of these are
manifestations of one problem, uremia
 A second-year resident might have recorded Problem List as having only one problem, uremia, and
included all other abnormalities under that problem
 Both Problem Lists are acceptable
• Second-year resident is reflecting a higher degree of understanding
• Following day clerk's Problem List could be modified to facilitate more precise (and less lengthy)
daily progress notes
Prob.# Date Entered Problem List Problem Resolved
1 5/2/16 BUN 5/3 uremia
2 5/2/16 K 5/3 See #1
3 5/2/16 Muscle twitching 5/3 See #1
4 5/2/16 Pericardial friction rub 5/3  See #1
5 5/2/16 Vomiting 5/3  See #1
6 5/2/16 Confusion 5/3 See #1
 Resolving problem 2-6 under 1, uremia allows one daily progress note to be
written for that problem and tells an observer reading pt.'s chart that all signs
(Sn) and symptoms (Sx) in problems 2-6 are related to manifestations of uremia
 date 5/3 tells observer to see notes of that day to explain redefining of
Problem List
B. Problem List must include all abnormalities noted in initial data base
Imhotep
Marc Again, each abnormality need not be separately recorded, as explained above
Cray, M.D. 10
C. The Problem List is refined as problems are either resolved
or further defined
1. Example Problem Resolved:
 A pt. is admitted with a fever and cough productive of yellow
sputum which on Gram stain reveals Gram positive intracellular
diplococci
 Pt. is treated for seven days with penicillin and problem
clinically and radiologically resolves
1 5/2 pneumococcal pneumonia 5/9 
 date 5/9 refers an observer to that date's progress note which will
explain why problem is considered resolved

2. Example Problem Further Defined:
 Consider first example of patient with uremia
 On day 5/7 a renal biopsy is done which reveals etiology of renal
failure Problem List would then show:
Problem
Prob.# Date Entered Problem List
Resolved
BUN 5/3 Uremia 5/7 Secondary to
1 5/2
membranous glomerulonephropathy
 Again the date of 5/7 will refer reader to progress note for that day
which should reveal result of renal biopsy

D.If initial data base is incomplete, Problem List must state so
Example: A FM patient who is admitted w upper GI bleeding has not had
a pelvic exam in 2 years
 A pelvic and Pap Smear are not done on admission b/c pt. is unstable
 Problem list must include a problem that states
Incomplete Data Base
2 5/2
Pelvic/Pap Not Done
 Once pt. is stable and pelvic exam/Pap smear is done, the problem is resolved
Incomplete Data Base 5/9
2 5/2 Pelvic/Pap Done-Nml
Pelvic/Pap Not Done
E. The Positive Review of Systems: Many physicians wonder what to do

with pt. who answers affirmatively for every question asked in review of
systems(ROS)
 Does each positive have to be recorded separately?  Obviously not!
Example: For an elderly, lonely FM who is admitted w a hip fracture and
whose PE nml except for hip and whose answers are positive for every
question asked in ROS physician could list the problems:
 #1 - Fracture left hip, and
 #2 - Positive review of systems
 Or, recognizing that all these affirmatives may be manifestations of
depression physician could list #2 - Depression
Initial Plans
 Next process that a physician undertakes after deciding

"what is wrong" is "what to do about what is wrong"
 This is the initial plan and must be written by admitting

physician after Problem List is constructed
 For each problem defined, a SOAP note must be recorded

Initial Plans (2)
 Each separate problem is named and described in write up and,
subsequently, on the progress note in a SOAP format:
 S, subjective data from the patient's point of view
 O, objective data acquired by inspection, percussion,
auscultation, and palpation and from laboratory and
radiologic tests etc.
 A, assessment of problem  an analysis of subjective and
objective data, and
 P, plan, including further diagnostic work, therapy, and
education and (or) counseling

Initial Plans (3)
Again, for each problem defined, a SOAP note must be recorded
Subjective and Objective are each a brief review of abnormalities

identified in history, physical, and initial lab data, which pertain to
that particular problem
 These need not be lengthy, but simply one or two lines
reviewing pertinent data

Initial Plans (4)
 Assessment is a brief but pertinent paragraph describing what
physician thinks about that particular problem
 If problem recorded is a sign or symptom requiring a differential

diagnosis the DDx must be recorded in a prioritized manner with a
brief statement as to why physician includes the differential that he or
she does
 If problem is a known diagnosis (Ex.-asthma) physician must include

in Assessment a statement that describes severity and why problem
has worsened requiring admission to hospital
Initial Plans (5)
Plan must include three distinct groupings:
1. Diagnostic Plan:
 diagnostic plan includes all diagnostic workup which admitting physician
feels will be necessary
 If Assessment includes differential diagnosis, each must be ruled in or
ruled out in diagnostic plan may be done by way of a Venn diagram
 Example: Consider a 23 year old FM admitted with pleuritic chest pain for which
admitting physician includes pulmonary embolus, pericarditis, or viral pleuritis in
differential diagnosis The diagnostic plan may be as follows:

Initial Plans (6)
 If problem is a known diagnosis, then diagnostic plan must include
additional workup needed either to further define problem or to
assess severity of problem
2. Therapeutic Plan: Must detail all initial therapies started and
their rational
3. Patient Education Plan: Details initiation of plans to educate

patient of what problem is and how pt. will deal with it in
future

Daily Progress Notes
 Many physicians object to POMR b/c its use results in lengthy,
redundant progress notes
 However, when used properly, POMR does just the opposite and
results in notes that are clear, direct, brief and complete
 A few helpful hints regarding SOAP progress notes are:

a. A note for each active problem identified need not be written
every day
 If nothing has changed regarding a particular problem, a
note for that problem need not be written
o An observer will refer back to prior day=s note to get a
progress report on that particular problem
Daily Progress Notes (2)
b. The S, O, A, or P need not be rewritten if nothing is changed for that

particular aspect of the problem
c. A common error in writing daily progress notes concerns restating

problem under Assessment in daily note
 Example: If problem is congestive heart failure, Assessment for that
particular problem on any day cannot be “CHF"  This is simply a
restatement of problem
o However, physician must give a status report (example - better,
worse, or etiology determined) under assessment
Final Progress Note or Discharge Summary
 Final progress note should include all active problems, each defined
as to its furthest resolution on Problem List
 The Subjective should include a brief review of course of symptoms

 The Objective should review course of objective parameters
 The Assessment and Plan should include probable course to follow
and define end-points as a guide for further therapy
 Emphasis on final progress note should be unresolved problems

 Problems which are resolved can be written up briefly

The SOAP Note
“SOAP note originated from POMR”
24
Components of a SOAP note
 The four components of a SOAP note are:
Subjective,
Objective,
Assessment, and
Plan
 Length and focus of each component of a SOAP note vary

depending on specialty for instance, a surgical SOAP note
is likely to be much briefer than a medical SOAP note, and
will focus on issues that relate to post-surgical status
Subjective component
 Initially is patient's Chief Complaint, or CC
 This is a very brief statement of patient (quoted) as to purpose of
office visit or hospitalization
 If this is first time a physician is seeing a patient physician will take a

detailed History of Present Illness (HPI)
 This describes patient's current condition in a chronological
narrative form
 HPI or state of experienced symptoms should be recorded in
patient's own words

Subjective component (2)
 All information pertaining to subjective information is
communicated to physician by patient or his/her representative
 It should include all positive and pertinent negative symptoms
 Pertinent past medical history and surgical history, family history,

and social history, along with current medications, smoking status,
drug/alcohol/caffeine use, level of physical activity and allergies, are
also recorded
 Subsequent visits for same problem briefly summarize HPI, including
pertinent testing + results, referrals, treatments, outcomes and follow-ups

 The mnemonic below refers to information a physician should elicit
(using pain as CC) before referring to patient's "old charts" or "old carts"
Onset
Location
Duration
CHaracter (sharp, dull, etc.)
Alleviating/Aggravating factors
Radiation
Temporal pattern (every morning, all day, etc.)
Severity

Variants on “old carts” include LOCQSMAT (and OPQRST, to follow.)
Location
Onset (when and mechanism of injury - if applicable)
Chronology (better or worse since onset, episodic, variable, constant,
etc.)
Quality (sharp, dull, etc.)
Severity (usually a pain rating)
Modifying factors (what aggravates/reduces symptoms - activities,
postures, drugs, etc.)
Additional symptoms (un/related or significant Sx to the chief CC)
Treatment (has pt. seen another provider for this symptom?)
 OPQRST is a mnemonic used by medical professionals to accurately
discern reasons for a patient's symptoms and history in event of an
acute illness
 NB: It is specifically adapted to elicit Sx of a possible MI
 Each letter stands for an line of questioning for pt. CC evaluation

 Onset of the event
 Provocation or palliation
 Quality of the pain
 Region and radiation
 Severity
 Time (history)
 OPQRST is usually taken along w Vital Signs and SAMPLE history (next slide)
 recorded by person delivering care such as in "Subjective" portion of a
SOAP note, for later reference
o "PQRST" (omitting "O") is sometimes used instead
o The term "OPQRST-AAA" adds
• “Aggravating/alleviating factors",
• “Associated symptoms", and
• “Attributions/adaptations"

 A SAMPLE history is one method of obtaining information from a patient
 SAMPLE history is an mnemonic acronym to remember key questions for a
person's medical assessment (most commonly used in emergency medicine)
S – Signs/Symptoms (Sx are important but they are subjective)
A – Allergies
M – Medications
P – Past Illnesses
L – Last Oral Intake (sometimes also Last Menstrual Cycle)
E – Events Leading Up To Present Illness / Injury history which places a
greater emphasis on a person's medical history
 Again, SAMPLE Hx is sometimes used in conjunction w VS and OPQRST

Parts of mnemonic OPQRST
Onset of the event
 What patient was doing when it started (active, inactive,
stressed)
 Whether pt. believes activity prompted pain, and
 Whether onset was sudden, gradual or part of an ongoing
chronic problem
Provocation or palliation
 Whether any movement, pressure (such as palpation) or
other external factor makes problem better or worse
 This can also include whether symptoms relieve with rest

Parts of mnemonic OPQRST (2)
Quality of the pain
 This is patient's description of pain
o Questions can be open ended ("Can you describe the
pain for me?") or leading (“Is the pain sharp or dull?”)
 Ideally, this will elicit descriptions of patient's pain:

o whether it is sharp, dull, crushing, burning, tearing, or
some other feeling, along with pattern, such as
intermittent, constant, or throbbing

Region and radiation
 Where pain is on body and whether it radiates (extends) or
moves to any other area
o This can give indications for conditions such as a
myocardial infarction can radiate through jaw neck
and arms
• Other referred pains can provide clues to underlying medical
causes

Severity = Pain score (usually on a scale of 0 to 10) Zero is no pain and
ten is the worst possible pain
 Can be comparative (such as "... compared to t worst pain you have ever
experienced") or imaginative ("... compared to having your arm ripped off ")
o If pain is compared to a prior event, nature of that event may be a
follow-up question
 Physician must decide whether a score given is realistic within their

experience  for example, a pain score 10 for a stubbed toe is likely to be
exaggerated
 This may also be assessed for pain now, compared to pain at time of
onset, or pain on movement
Time (history)
 How long condition has been going on and how it has
changed since onset (better, worse, different symptoms)
 Whether it has ever happened before
 Whether and how it may have changed since onset, and
 When the pain stopped if it is no longer currently being felt

Objective component
The objective section of SOAP includes information that physician
observes, elicits and measures from patient's current presentation
Objective component includes:

 Vital signs (Temp., BP, Pulse, RR, ) and measurements, such as Weight and Height
 Findings from physical examinations, including
 Basic systems of cardiac and respiratory, affected systems
 Possible involvement of other systems,
 Pertinent normal findings and abnormalities
 Results from laboratory and other diagnostic tests already completed
 Medication list obtained from pharmacy or medical records

Assessment
 A medical diagnosis (Dx) for purpose of medical visit on given date of
note written
 it is a cogent & concise summary of patient w main
Sx/Sn/Labs=Dx, including a differential diagnosis (DDx) a list of
other possible diagnoses in order of most likely to least likely
 Assessment will also include possible and likely etiologies of patient's

problem
 Assessment also records a patient's progress since last visit, and

overall progress towards patient's goal from physician's perspective
Plan
 Plan is what physician will do to treat patient's concerns (problems) 
such as ordering further labs, radiological work up, ECG, referrals given,
procedures performed, medications given and education/ counseling
provided
 Plan should also include goals of therapy and patient-specific drug and
disease-state monitoring parameters
 This should address each item of differential diagnosis
 For patients who have multiple health problems that are addressed in
SOAP note a plan is developed for each problem and is numbered
accordingly based on severity and urgency for therapy
A note of what was discussed or advised with pt. as well as timings for
further review or follow-up should also be included
Note: Often
Marc Imhotep Cray,Assessment
M.D. and Plan components are grouped together 40
Example SOAP note
 Example for a patient being reviewed following an appendectomy
 resembles a surgical SOAP note medical notes tend to be more detailed,
especially in subjective and objective components
Surgery Service, Dr. J
No further Chest Pain or Shortness of Breath. "Feeling better today." Patient
S:
reports headache.
O: Afebrile, P 84, R 16, BP 130/82. No acute distress.
Neck no JVD, Lungs clear
Cor RRR
Abd Bowel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean.
Ext without edema
Patient is a 37-year-old man on post-operative day 2 for laparoscopic appendectomy.
A:
Recovering well.
Advance diet. Continue to monitor labs. Follow-up with Cardiology within three days of
P:
discharge
Marc Imhotep for stress testing as an out-patient. Prepare for discharge home tomorrow morning.
Cray, M.D. 41
Example SOAP note (2)
 The plan (previous slide) itself includes various components:
 Diagnostic component - continue to monitor labs
 Therapeutic component - advance diet
 Referrals - Follow up with Cardiology within three days of discharge
for stress testing as an out-patient.
 Patient education component - that is progressing well
 Disposition component - discharge to home in the morning

THE END
See next slide for links to tools and resources for further study. 43
Further Study:
e-Book:
Kettenbach G. Writing SOAP Notes, 2nd Ed. Philadelphia PA: F. A. Davis Company, 1995.
https://drive.google.com/file/d/0B-tlCbPSHvfZamVyMjl0SFBvVDA/view?usp=sharing
Web:
 Alert: Lawrence Weed, father of the Problem Oriented Medical Record, looks ahead e-Patient Dave .November 28, 2011.
Available at: http://e-patients.net/archives/2011/11/alert-lawrence-weed-father-of-the-problem-oriented-medical-record-looks-
ahead.html
 Jacobs L. Interview with Lawrence Weed, MD—The Father of the Problem-Oriented Medical Record Looks Ahead. EDITORIAL: The
Permanente Journal/ Summer 2009/ Volume 13 No. 3 Available at
http://www.thepermanentejournal.org/files/Summer2009/Lawrence_Weed.pdf
 Donnelly WJ. Viewpoint: Patient-Centered Medical Care Requires a Patient-Centered Medical Record Pdf.
 Kernisan L. The Problem-Oriented Medical Record Available at http://thehealthcareblog.com/blog/2013/05/10/the-problem-
oriented-medical-record/ Accessed October 28, 2015
 Kernisan L. Medicine in Denial: What Larry Weed Can Teach Us About Patient Empowerment. The Health Care Blog (This post is
Part 2 of a commentary on “Medicine in Denial,” (2011) by Dr. Lawrence Weed and Lincoln Weed.) Available at:
http://thehealthcareblog.com/blog/2013/05/22/medicine-in-denial-what-larry-weed-can-teach-us-about-patient-
empowerment/ Accessed October 28, 2014
 Salmon P, Rappaport A, Bainbridge M, Hayes G, Williams J. Taking the problem oriented medical record forward. Primary Health
Care Specialist Group of the British Computer Society. https://drive.google.com/file/d/0B-
tlCbPSHvfZMlZnMU9sRFBNUWM/view?usp=sharing
 The SOAP format enhances communication: the SOAP format provides a clear and concise way of documenting patient
information. https://drive.google.com/file/d/0B-tlCbPSHvfZYVdGSy15NzhwRjg/view?usp=sharing

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POMR and SOAP Notes

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The Problem Orientated Medical Record

(POMR) and SOAP Note

Prepared and presented by

 POMR preserves data in an easily accessible way that encourages

Marc Imhotep Cray, M.D. 3

 Data Base must include a complete history and physical exam

Marc Imhotep Cray, M.D. 5

 Construction of a Problem List is the initial step of what physicians

Marc Imhotep Cray, M.D. 6

 Physicians often get caught up in defining Problems and Problem

Marc Imhotep Cray, M.D. 8

 The student lists each of these abnormalities as a separate problem

Marc Imhotep Cray, M.D. 11

Marc Imhotep Cray, M.D. 12

E. The Positive Review of Systems: Many physicians wonder what to do

 Next process that a physician undertakes after deciding

 This is the initial plan and must be written by admitting

Marc Imhotep Cray, M.D. 15

Marc Imhotep Cray, M.D. 16

Subjective and Objective are each a brief review of abnormalities

Marc Imhotep Cray, M.D. 17

 If problem recorded is a sign or symptom requiring a differential

 If problem is a known diagnosis (Ex.-asthma) physician must include

Marc Imhotep Cray, M.D. 19

3. Patient Education Plan: Details initiation of plans to educate

Marc Imhotep Cray, M.D. 20

 A few helpful hints regarding SOAP progress notes are:

b. The S, O, A, or P need not be rewritten if nothing is changed for that

c. A common error in writing daily progress notes concerns restating

 The Subjective should include a brief review of course of symptoms

 Emphasis on final progress note should be unresolved problems

Marc Imhotep Cray, M.D. 23

“SOAP note originated from POMR”

 Length and focus of each component of a SOAP note vary

 If this is first time a physician is seeing a patient physician will take a

Marc Imhotep Cray, M.D. 26

 It should include all positive and pertinent negative symptoms

 Pertinent past medical history and surgical history, family history,

Marc Imhotep Cray, M.D. 27

Marc Imhotep Cray, M.D. 28

 Each letter stands for an line of questioning for pt. CC evaluation

Marc Imhotep Cray, M.D. 31

 Again, SAMPLE Hx is sometimes used in conjunction w VS and OPQRST

Marc Imhotep Cray, M.D. 33

 Ideally, this will elicit descriptions of patient's pain:

Marc Imhotep Cray, M.D. 34

Marc Imhotep Cray, M.D. 35

 Physician must decide whether a score given is realistic within their

Marc Imhotep Cray, M.D. 37

Objective component includes:

Marc Imhotep Cray, M.D. 38

 Assessment will also include possible and likely etiologies of patient's

 Assessment also records a patient's progress since last visit, and

Marc Imhotep Cray, M.D. 42

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