Checkpoint Record Formats - patient The final component is...

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Source orientated records is the traditional format for patient records. This format keeps all notes that are created by a doctor in one section, all notes created by the nursing staff in another, and so forth. This type of record links all documentation to one specific problem, but it creates many different sections in the chart and its hard to follow one specific problem Problem orientated records are more systematic approach to documentation and has four components. The first component is the database, which contains information such as the chief complaint, present condition, diagnosis, social data, baseline laboratory, and physical examination. The second component is the problem list this is like a table of contents for the patients record it lists the patient’s problems. The third component is the initial plan that provides the plan that will be taken to treat the patients condition as well as what will be done to learn more about the condition, and provide education to the
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Unformatted text preview: patient. The final component is the progress notes which depending on the situation will summarize many different things such as the patient’s response to treatment, care, and the patient’s condition when discharged. This format is organized and easy to follow the course of treatments that have already been done and the response that the patient had, filing of these reports are time consuming and training is required, data that is associated with more than one problem has to be documented in multiple places. Integrated records arranges and patient record in chronological date order this format allows for observations on the patients is progressing according to test results, treatments, All information on a patients health issue is filed together. This format is less time consuming because when it comes to filing reports, but makes it difficult to compare and retrieve information from the same discipline....
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