Check Point: Record Formats
October 4, 2012
Many hospitals, clinics, and physicians offices maintain patient records in paper format which is also known as a manual record. There are several ways to maintain patient records, including source oriented records (SOR), problem oriented records (POR), and integrated records. The source oriented records (SOR) are information about a patient’s care categorized and organized by the “source” of the information provided for the patient. Records are kept together by subject matter, for example; lab information are all together in one section, progress notes are all together, xray or laboratory tests are filed under a specific label, and so forth. The problem oriented records (POR) is recording important data about the health status of a patient in a problem-solving system. This data base gathers together all findings relative to a specific problem in the patient’s medical record, so physicians and nurses can share the knowledge of specific problems to plan their course of action that needs to be taken. It also consists of an initial plan and progress notes in the patient’s record. Problems include anything that requires diagnostic reviews, abnormal findings, and symptoms; also considered as a problem are medical, economic, and financial issues. The initial plan is a strategy that describes what actions should be taken to treat the patient’s issues. Also used to document problems and notes is a SOAP structure which includes; subjective-a statement about how they feel; objective-observations of the patient; assessment-opinion or evaluation made by the physician; plan-diagnostic, plans to resolve the problems. The integrated medical record (IMR) are reports used in chronological date order. This type of record lets you know how the patient is progressing depending on the test results that were given based on the treatment. Physicians and nurses should be very committed to filling out progress notes. It is...
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