Essentials of Health Information Management
Essentials of Health Information Management
Paula Rose
HCR/210
October 27, 2011
Lyndsey Jacobs
Essentials of Health Information Management
Source- oriented medical records are kept together by subject matters, such as data from all laboratory results. Progress notes are all kept together and are written in paragraph format; these entries are filed under a specific sectionalized area in the patient chart and are usually in chronological order. Many facilities use the chronological order because this is an easy way to locate the required documents. The major advantage is that information is organized together, which makes it easier to determine the assessment, treatment, and observations a particular department provided a patient. The major disadvantage is there is no possible way to quickly determine all of the patient problems or treatment that has been provided to the patient.
Problem- oriented medical records are kept together by a problem number; with this a number is placed to each problem. This is the most traditional way that most physicians document his or her records. Progress notes are kept in a “SOAP format, which is S= subjective, O=objective, A= assessment, and P= plan of action.” (SOAP Notes, 2010) The problem oriented-medical records have four parts, which include a database, problem list, initial plan, and progress notes. The major advantage is the record format is the ease or progression through all the data. The data is organized into stratified sections, which is quicker to find information needed and allows for a more rapid review of multiple office vists over time. The major disadvantage is that this type of format requires additional training and commitment from the medical and professional staff.
An integrated record is a combination of source- oriented and problem- oriented medical records. The records are arranged in a strict chronological order, regardless of the source of original information. This method keeps a good account
Paula Rose
HCR/210
October 27, 2011
Lyndsey Jacobs
Essentials of Health Information Management
Source- oriented medical records are kept together by subject matters, such as data from all laboratory results. Progress notes are all kept together and are written in paragraph format; these entries are filed under a specific sectionalized area in the patient chart and are usually in chronological order. Many facilities use the chronological order because this is an easy way to locate the required documents. The major advantage is that information is organized together, which makes it easier to determine the assessment, treatment, and observations a particular department provided a patient. The major disadvantage is there is no possible way to quickly determine all of the patient problems or treatment that has been provided to the patient.
Problem- oriented medical records are kept together by a problem number; with this a number is placed to each problem. This is the most traditional way that most physicians document his or her records. Progress notes are kept in a “SOAP format, which is S= subjective, O=objective, A= assessment, and P= plan of action.” (SOAP Notes, 2010) The problem oriented-medical records have four parts, which include a database, problem list, initial plan, and progress notes. The major advantage is the record format is the ease or progression through all the data. The data is organized into stratified sections, which is quicker to find information needed and allows for a more rapid review of multiple office vists over time. The major disadvantage is that this type of format requires additional training and commitment from the medical and professional staff.
An integrated record is a combination of source- oriented and problem- oriented medical records. The records are arranged in a strict chronological order, regardless of the source of original information. This method keeps a good account