Papierbasierte Patientenakten: 4 Typen, Organisation und Anwendungsfälle

Before EHRs, paper records were organized in four principal formats:

• Source-Oriented Medical Record (SOMR) – Organized by discipline/department (physician notes, nursing notes, lab, radiology, pharmacy). Most common in small practices; easy to file, hard to synthesize.
• Problem-Oriented Medical Record (POMR) – Organized by patient problem list (Weed, 1960s). Each problem has: database, plan, progress notes (SOAP). Improves care coordination; standard in academic/teaching settings.
• Chronological Medical Record – All entries filed sequentially by date regardless of source. Used in EDs/urgent care for real-time documentation flow.
• Flow Sheet / Graphic Record – Trend graphs of vitals, I&O, labs, ventilator settings. Critical care, OR, anesthesia; enables rapid pattern recognition.

Most modern EHRs blend these paradigms (problem list + chronological encounter view + flowsheets). Understanding the legacy structures informs data migration and clinical workflow design.