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The Medical Record

At the start of each day a completed Medical Record needs to be submitted by your clinics.

At each submission period, your clinics will submit part or all of their medical record. Make sure you speak with your clinics on Day 1 to clarify what you would like them to turn in at each submission.

To aid in the process, the students have been asked to keep their medical records organized, complete, and free of excess paper. This can allow you to fully evaluate their record and follow their thought process.

POMR is usually organized from front to back as:

  • Master Problem List (updated daily & always on top)
  • History (completed VTH form)
  • Physical Exam (completed VTH form)
  • Daily Progress Reports (SOAP's)
  • Laboratory Data (results)
  • Miscellaneous - client communication forms, client instruction forms/letters, etc.

Resources for writing and evaluating SOAP's:

The medical records and introduction to writing academic SOAP's is a large portion of the Diagnostic Challenge experience for the students.

Our students are hungry for feedback, and providing quality feedback in a timely manner is very beneficial to continue moving forward with their cases.

For providing feedback on SOAP's and MPL - SOAP-POMR Rubric

Examples:

 

Academic SOAPs and the DC Exercise = Practice and Feedback - handout

Washington State University