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HCR 210 Week 3-Checkpoint - Record Formats

HCR 210 Week 3-Checkpoint - Record Formats - chronological...

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Source oriented records maintain records according to the source of documentation. Documents generated by the nursing staff are located in the nursing section of the chart. Radiology reports are located in the radiology section and physician documents are located in the medical section. Problem oriented records consist of four components. The four components are database, problem list, initial plan, and progress notes. The database is an overview of the patient’s information. The problem list contains a list of the patient’s problems. The initial plan describes actions that will be taken to learn more about the patient’s condition and to treat the patient. The progress note is where the discharge summary is located. The progress note contains the patients care, treatment, response to care, and condition on the patients discharge. Integrated records are arranged in
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Unformatted text preview: chronological order this allows for observation of how a patient is responding to treatment based on test results. There are some disadvantages and advantages to each of these record formats. Source oriented records would be easy to locate information, but also difficult to follow one diagnoses. Problem oriented records links all documentation to a specific problem and facilitates patient treatment and education, but this format requires training and one problem must be documented several times. With source oriented records and problem oriented records it would be time consuming when filing the information. Integrated records are easier to use and all information on a patients care are filed together. Integrated records make it difficult to compare and retrieve information from the same discipline, but they are less time consuming to file the reports....
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