MODELS OF HEALTH
INFORMATION MANAGEMENT
(MEDICAL RECORD KEEPING)
DR: Al-Zahraa Fekry
Lecturer Of Physical Therapy
Basic Science Department
types of documentation formats used 4
-:in physical therapy
a) SOAP notes
b) Problem-oriented medical records (POMR)
c) Systems-based medical records (SOMR)
d) functional outcomes reporting (FOR)
Systems-based medical records (SOMR):-
• (SOMR): offer a structured approach that organizes
information based on the documentation source, such as
progress notes, lab reports, physical therapy records, and
group information.
• Unlike problem-oriented medical records, which organize
data around a patient's specific health issues, SOMR
maintains separate sections for each data type.
• This traditional method, whether in paper form or
integrated into an electronic health record (EHR) system,
ensures that all pertinent medical record information is
easily accessible and systematically arranged, enhancing
patient care efficiency.
:components of SOMR
• Patient information: The patient records are based on
basic details such as the patient's name, age, marital status,
and contact information.
• Medical history: A comprehensive overview of the
patient's diagnoses, past illnesses, surgeries, and family
health history is crucial for understanding the patient's
overall health context.
• Progress notes: Daily or periodic entries by healthcare
providers documenting the condition, treatment, and
patient progress are maintained in chronological order.
• Physician orders: Doctor instructions regarding
medications, treatments, and other interventions, ensuring
that all directives are recorded and followed.
:components of SOMR
• Laboratory data: Results from blood tests, imaging
studies, and other diagnostic tests, organized for easy
reference and analysis.
• Assessment and treatment plans: Detailed plans
and evaluations, including the initial assessment and
subsequent updates, outlining the approach to
managing the patient's health problems.
• Departmental records: Specific notes and data
from various hospital departments, such as physical
therapy or radiology, provide a complete view of the
patient's interactions with different care areas.
: Advantages of using SOMR
By organizing patient information in this
structured manner, source-oriented medical
documentation enhances the efficiency and
effectiveness of patient care. It ensures that all
healthcare providers have easy access to
essential data and that there is no duplicated or
missed information.
-:Functional outcomes reporting (FOR)
• Functional outcome reporting: quantify a
patient's function improvement throughout an
episode of care.
• Physical therapy outcome measures allow
therapists to create a definitive baseline of patient
ability and compare advancements in function in
real-time.
• They enable providers to document the
effectiveness of treatment and improve care
where necessary.
-:Functional outcomes reporting (FOR)
• Functional outcome measures offer objective ways to assess
a patient’s physical abilities, monitor progress, and guide
treatment plans.
• These measures are often used during the initial evaluation
to establish a baseline, periodically throughout care to track
improvements, and at discharge to determine overall success.
• They provide standardized methods for identifying deficits
in strength, balance, mobility, or coordination and allow
therapists to communicate progress effectively with patients
and other healthcare providers.
• By incorporating these tools, physical therapists can create
personalized, data-driven interventions to help patients
regain function and improve their quality of life.
-:Advantages of Functional outcomes reporting (FOR)
• FOR allow providers to quantify patient
improvement over time reliably.
• It can be used to compare a patient's current
improvement timeline to similar patients of the
same age, weight, and condition.
• If a patient does not similarly respond to
treatment, providers can re-evaluate the patient to
determine a more effective care plan.
• In this way, providers, patients, and payers receive
evidence-based care.
Advantages of Functional outcomes reporting (FOR):-
• outcome reporting allow patients to remain
engaged with their care.
• Enable patients to observe improvements in their
function throughout treatment, from intake to
discharge, to inspire them to actively contribute to
their care plan.
• Providers can also use patient improvement and
engagement as the basis of local marketing
campaigns.
:Functional Outcome Measurement Examples
• Neck Disability Index (NDI)
• Functional Reach Test
• Lower Extremity Functional Scale (LEFS)
• Berg Balance Scale
