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Record Formats

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Submitted By m2013
Words 327
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Record Formats
HCR/210
Jennifer Briscoe
May 24, 2013

According to our textbook a traditional patient’s record is known as a source oriented record. What this means is whatever staff generates the records, the records are stored with that department. For example if a nurse generates a record for a patient the record will therefore stay in the nursing department. Reports from a physician are stored in the medical section. The advantage of this is if a physician’s needs to know the results of an x-ray he can easily look under the radiology section. The down fall to this would have to be if a physician wanted to see the patient’s diagnoses they will have to look under every department section to see what information they are looking for.
The problem oriented record consists of four components: data, problem list, initial plan, progress notes. An overview of the patient’s information is in the database, while the patient’s problems are in the problem list. The initial plan outlines the actions that will be taken to determine the condition of the patient as well as treatment. The discharge summary is in the progress note. It also details the care of the patient, his or her treatment and response to that care, and the patient’s condition when he or she is discharged
Records in chronological order are called integrated records. This type of record-keeping is good for keeping track of how a patient responds to treatment based on results from tests. Problem-oriented records require training and the same problem has to be documented several times, but all documentation is linked to a specific problem, which makes treatment and education of the patient easier. Both of these styles make filing time-consuming. With integrated record-keeping, the retrieval and comparison of information from the same discipline is difficult, but filing is less time-consuming, the records

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