Record Formats - The problem list will be filed at the...

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Record Formats Amber N. Hunter Beginning with a source oriented record; these are records that are organized through the source of the documents. This means that any lab work in the record would be located with the lab section in the record, or radiology with the radiology section, and so on. This can be a popular form of record keeping because when a physician or doctor needs something from a certain section it is easy to retrieve. Although, if the physician needs information on numerous things like diagnosis or a treatment given on a certain day, retrieval can be somewhat tedious. The problem oriented record, which was created in the 1960’s, was for a more systematic method of record keeping. This record format consists of four components which are database, problem list, initial plan, and progress notes. The database would act as an overview of the patient’s information such as, chief complaint, social data, past medical history, and so on.
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Unformatted text preview: The problem list will be filed at the beginning of the patient’s record and serve as a table of contents. This is because the problem list will contain a numbered list of the patient’s problems which will help to keep track of the documents throughout the records. Outlined in the initial plan would be the management of the patient’s condition. While this record format is highly organized, filing can be time consuming, and more than one problem must be documented numerous times causing more time consumption. Integrated record formats use either chronological order or reverse chronological order. This allows the records to be viewed on how the patient may or may not be progressing in treatment. While this format is easy to use, and takes less time in filing reports; it can also be difficult to retrieve and compare information from a same discipline....
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This note was uploaded on 10/10/2010 for the course SCI 275 SCI 275 taught by Professor Lee during the Spring '09 term at University of Phoenix.

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