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Records Format

In: Other Topics

Submitted By TracyShin
Words 353
Pages 2
Summarize in 250-300 words the differences among source-oriented records, problem-oriented records, and integrated records.
Include how you think the advantages and disadvantages of each record format affect every day work- remember to think about retrieving records as well as filing them.

Source-oriented records (SOR) maintain reports according to source of documentation. This means that whomever the document is generated by, whether it being a nurse, radiology, or a physician each has their own section in the patient records. Problem-oriented records (POR) or problem-oriented medical records (POMR) is a way of record keeping that focuses on a specific problem that a patient may be having, which uses four components database, problem list, initial plan, and progress notes to identify problems. In a POR patients are assigned one or more problems and notes are documented for each problem using the SOAP structure. SOAP is defined as subjective, objective, assessment, and plan. Subjective is a patient’s statement about how she/he feels. Objective is the observation of the patient. Assessment is the judgment, opinion, or evaluation made by the health care provider. Plan is the diagnostic, therapeutic, and educational plan to resolve the patient’s problem. Integrated records format is the arranging of reports in a chronological date order. This allows observation on how the patient is progressing according to test results and how well the patient is responding to treatment based on those test results to be documented. Well I think that the advantages and the disadvantages of all three records format on everyday work is what to be expected when dealing with patient records. Some advantages of all three is that it’s easy to use, less time consuming to file reports, makes it easy to locate information from the same patient, and makes it easier to file same source...

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