problem oriented medical record. clinical actions the most important clinical actions are not...
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Problem Oriented Medical Record
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Clinical Actions
The most important clinical actions are not procedures or prescriptions, but the judgments from which all other aspects of clinical medicine flow Diagnosis , diagnosis, and diagnosis
Daniel B Mark, 2008
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Hypothesis testing
Diagnosis
Treatment planning
Learning process
Patient management
Learn the disease based
data
Pathophysiology
Etiology
Hypothesis
Problems manifestation
Morphology, cell,
biochemical changing
Structure and function
disturbances
Learn the patients based
data
Sign & symptoms
Newly data
Newly data
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Perspective
In pathology we learn disease In clinical training we work with illness Ideally, the physician will think in terms of
both disease and illness Each such illness is a unique event. It
happens to a single individual over restricted period of time and will never happen again in precisely the same way
Disease, is an abstraction, illness is a process
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Perspective Students who never conceptualize the
distinction between disease and illness will make two errors
First, is to mistake the disease as a reality BP 150/90 becomes a disease rather than sign
of possible illness. If no other cause can be found, the patient is given a disease label, never mind that the patient is 90 years old the physician who has balances view of disease and illness will see the elevated BP as only a sign of disease, not the itself.
Second, is not to see the illness at all. There is indisputable merit in understanding
the total social and psychological forces impinging on the patient.
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Pemahaman Umum
• Data : raw material• Masalah : sesuatu yg harus ditindak
lanjutio Masalah test menuju DXo Diagnosis terapi
• Test : accuracy• Probability : diagnosis diferensial• Kriteria Dx : diagnosis pasti• Treatment : evidence based
• Catatan : kumpulan data pengkajian diagnosis pengkajian Tx
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Scientific MethodProblem Identification
Data Collection
Data Analysis
Synthezise Data
Hypothesis
Solution implemented
New Data
Planning Solution
Decision makingDecision making
SPSA
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Scientific Problem Solving
• Problem solving• Problem solving approach• Scientific problem solving
approachScientific problem solving approach1. roblem identification2. Data gathering3. Data analyzing4. Data synthesizing5. Problems formulation6. Problems solving7. Monitoring and evaluation
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Scientific Method
Identify the Problems
Collecting Data
Synthesis the Data
Hypothesis Developmen
t
Verification
Proved Hypothesis
New Hypothesis
Decision Making-For Dx tools- For Tx regimens- For prognostic
Solve the Problem
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SCIENTIFIC PROBLEMS SOLVING
APPROACH
S.P.S.A.
PROBLEM IDENTIFICATION
EVALUATION DATA COLLECTION
IMPLEMENTATION DATA ANALYSIS
PRIORITY SETTING HYPOTHESIS FORMULATION
PROBLEM SOLVING HYPOTHESISALTERNATIVE TESTING
CLINICAL PROCESS
HEALTH PROBLEM
FOLLOW-UP ANAMNESA/ P.D./ LAB. / MED-
RECORD
IMPLEMENTATION DATAS &
INFORMATION
ANALYSIS
TREATMENT DIAGNOSIS PRIORITY SETTING SYNTHESIS
TREATMENT DIAGNOSIS ALTERNATIVESPLANNING
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Scientific Thinking Paradigm
major to minor
minor to major
Hypothetic Verification
Deductive
Inductive
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?In the clinical setting
The patient
The health problems
Is it real problem?
Come to health center
Solve the problem
Decision making
Decision making
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The Similarity of Hypothesis & Diagnosis Testing
• Hypothesis testing • Diagnosis testing
Learn the patient
Learning of disease
Diagnosis / DD
Verification
• observe the patient• sensitivity / specificity of test
New informatio
n
Research data
Learning concept
hypothesis
Hypothesis test
• survey• experiment
New evidence
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The Step in Reaching Diagnosis
COLLECT INFORMATION
VERIFY INFORMATION AND CHECK IT’S CONSISTENCY
FORMULATE A DIFFERENTIAL
DIAGNOSIS
NEED MORE INFORMATION
IDENTIFY THE PROBLEM
• history taking• physical Examination•Laboratory/others data
FORMULATE A THERAPEUTIC
REGIMEN
Decision making
Decision making
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Clinical Process
Diagnosis Process
Therapeutic Process
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Clinical Process
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Complains Diagnose Treatment
DiagnosisProcess
Clinical Process
Therapeutic process
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BAGAN POMR
2. Identifikasi Masalah / Problem
1. PengumpulanData (Anamnesis, Pem.fisik, Lab, Foto dll )
3. Hipotesis Initial Diagnosis
5. Kesimpulan (diagnosis tetap)
4. Pengujian Hipotesis
Pengumpulan data
tambahan melalui Planning : - Anamnesis - Pemeriksaan fisik - Laboratorium - Foto / dll.
6. Terapi
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TAHAP – TAHAP P O M R
Data Dasar
Ax
Px
Lab
Px Tambahan
Interpretasi Data Abnormal
Daftar masalah sementara
Abnormal
Abnormal
Abnormal
Abnormal
Sintesis
(Kriteria Diagnosis)
Daftar Masalah Permanen
Diagnosis
Interpretasi data abnormal
Cost-Benefit Analysis
Rencana Awal :
Dx
Mx
Tx
Ex
Catatan KemajuanMasalah 1 S O A P : Dx Mx Tx ExMasalah 2Masalah n
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P.O.M.R
BASE LINE DATA
CLUE AND CUE
PROBLEM LIST / DIAGNOSISPLANNING
Dx Tx Edu.
1.2.3.4.5.
1.Problem 2.problem3.Diagnosis 4. Problem
SUBJECTIVE OBJECTIVE ASSESMENT PLANNING
Dx Tx Edu
FOLLOW UP
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Naïve Patient Management
• Primary surveyo Emergency caseo Urgency caseo A, B, Co stabilization
• Secondary surveyo Data findingo Confirm diagnoseo Treatment
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Summary
The clinical process in an implementation of scientific method to resolve clinical problem
Consist of: Scientific problem solving approach Decision making (in diagnosis & therapeutic process)
Diagnosis is an abstraction of disease They need diagnosis criteria (based on sign &
symptoms) No tools of diagnosis has 100% specificity &
sensitivity Think about probability in diagnosis & treatment
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Integration of Clinical Data and Suporting Test
Anamnesa Physical Exam Test Result
Nominal DataOrdinal Data Metrics Data
- clinical knowledge base- experience base
Problem / Diagnose
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Problem Solving Approach in Clinical Setting
1. Scientific Problem Solving Approach
2. Decision Making