Problem Oriented Medical Record

1. Problem Oriented Medical Record

2. 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

3. Learning process Learn the disease based data Etiology Pathophysiology Morphology, cell, biochemical changing Hypothesis Hypothesis testing Newly data Structure and function disturbances Diagnosis Newly data Problems manifestation Treatment planning Sign & symptoms Learn the patients based data Patient management

4. 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

5. 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.

6. PemahamanUmum • Data :  raw material • Masalah :  sesuatuygharusditindaklanjuti • Masalah  test  menuju DX • Diagnosis  terapi • Test :  accuracy • Probability :  diagnosis diferensial • KriteriaDx :  diagnosis pasti • Treatment :  evidence based • Catatan : kumpulan data  pengkajian  diagnosis  pengkajian  Tx

7. Scientific Method Problem Identification New Data Data Collection SPSA Solution implemented Data Analysis Planning Solution Synthezise Data Decision making Decision making Hypothesis

8. Scientific Problem Solving • Problem solving • Problem solving approach • Scientific problem solving approach Scientific problem solving approach • roblem identification • Data gathering • Data analyzing • Data synthesizing • Problems formulation • Problems solving • Monitoring and evaluation

9. Scientific Method Identify the Problems Collecting Data • Decision Making • For Dx tools • For Tx regimens • For prognostic Synthesis the Data Hypothesis Development New Hypothesis Verification Proved Hypothesis Solve the Problem

10. S.P.S.A. PROBLEM IDENTIFICATION EVALUATION DATA COLLECTION IMPLEMENTATION DATA ANALYSIS PRIORITY SETTING HYPOTHESIS FORMULATION PROBLEM SOLVING HYPOTHESIS ALTERNATIVE TESTING CLINICAL PROCESS HEALTH PROBLEM FOLLOW-UP ANAMNESA/ P.D./ LAB. / MED-RECORD IMPLEMENTATION DATAS & INFORMATION ANALYSIS TREATMENT DIAGNOSIS PRIORITY SETTING SYNTHESIS TREATMENT DIAGNOSIS ALTERNATIVES PLANNING SCIENTIFIC PROBLEMS SOLVING APPROACH

11. Scientific Thinking Paradigm major to minor Deductive Hypothetic Verification Inductive minor to major

12. ? In the clinical setting The patient Come to health center The health problems Decision making Is it real problem? Solve the problem Decision making

13. Hypothesis testing Diagnosis testing The Similarity of Hypothesis & Diagnosis Testing Learn the patient Research data hypothesis Diagnosis / DD Learning concept Learning of disease Verification Hypothesis test • observe the patient • sensitivity / • specificity of test New information New evidence • survey • experiment

14. The Step in Reaching Diagnosis IDENTIFY THE PROBLEM • history taking • physical Examination • Laboratory/others data COLLECT INFORMATION NEED MORE INFORMATION VERIFY INFORMATION AND CHECK IT’S CONSISTENCY Decision making FORMULATE A DIFFERENTIAL DIAGNOSIS Decision making FORMULATE A THERAPEUTIC REGIMEN

15. Clinical Process Diagnosis Process Therapeutic Process

16. Clinical Process

17. Diagnosis Process Therapeutic process Complains Diagnose Treatment Clinical Process

18. BAGAN POMR • PengumpulanData (Anamnesis, Pem.fisik, Lab, Fotodll ) 6. Terapi 2. IdentifikasiMasalah / Problem 5. Kesimpulan (diagnosis tetap) 4. PengujianHipotesis Pengumpulan data tambahanmelaluiPlanning : - Anamnesis - Pemeriksaanfisik - Laboratorium - Foto / dll. 3. Hipotesis Initial Diagnosis

19. TAHAP – TAHAP P O M R CatatanKemajuan Masalah 1 S O A P : Dx Mx Tx Ex Masalah 2 Masalah n Daftarmasalahsementara Abnormal Abnormal Abnormal Abnormal Data Dasar Ax Px Lab PxTambahan DaftarMasalahPermanen Diagnosis Interpretasi data abnormal RencanaAwal : Dx Mx Tx Ex Sintesis (Kriteria Diagnosis) Cost-Benefit Analysis Interpretasi Data Abnormal

20. P.O.M.R FOLLOW UP

21. Naïve Patient Management • Primary survey • Emergency case • Urgency case •  A, B, C •  stabilization • Secondary survey • Data finding • Confirm diagnose • Treatment

23. 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

24. Integration of Clinical Data and Suporting Test Anamnesa Physical Exam Test Result Nominal Data Ordinal Data Metrics Data • clinical knowledge base • experience base Problem / Diagnose

25. Problem Solving Approach in Clinical Setting 1. Scientific Problem Solving Approach 2. DecisionMaking