CheckPoint: Record Formats
* Resource: Ch. 4 of Essentials of Health Information Management: Principles and Practices 1.
Summarize, in 250 to 300 words, the differences among source oriented records, problem oriented records, and integrated records. 2.
Include how you think the advantages and disadvantages of each record format affect everyday work—remember to think about retrieving records as well as filing them. 3. Post your CheckPoint in your Assignment Section as an MS-Word document.
Many facilities and physician offices maintain patient records in a paper format known as a manual record. A variety of formats are used to maintain manual records, including the source oriented records (SOR), problem oriented records (POR), and integrated records. In a source oriented medical record (SOR), the information about a patient's care and illness is organized according to the "source" of the information within the record, that is, if it is recorded by the physician, the nurse, or data collected from an xray or laboratory test are filed under their specific sectionalized areas in the chart usually in chronological order. Many facilities use this format since it is easy to locate documents. For example, if a physician needs to reference a recent lab report, it can easily be found in the laboratory section of the record. However, if a physician wanted to reference all information about a particular diagnosis being treated or treatment given on a particular day, many sections of the record would have to be referenced making it difficult to amass all the information for that specific diagnosis difficult.
For PORs, we will define problem as anything that interferes with the health, well being and quality of life of an individual, that may be medical, surgical, obstetric, social or psychiatric, the problem oriented medical record (POR) has four parts: 1.
Database: Is an overview of patient information. The...
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