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CheckPoint - Record Formats

CheckPoint - Record Formats - keeping is good for keeping...

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CheckPoint: Record Formats Maintaining records based on the source of documentation is source-oriented records. When the nursing staff generates documents, those are placed in the chart’s nursing section. Reports for the physician are placed in the medical section, and reports form the radiology can be found in the chart’s radiology section. Four components make up problem-oriented records: database, list of problems, initial plans, and notes on progress. 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 the chronological order are caller integrated records. This type of record-
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Unformatted text preview: keeping is good for keeping track of how a patient responds to treatment based on results from tests. Each style of record keeping has advantages and disadvantages. In source-oriented records, the information is easy to locate, but may also be difficult for medical personnel to follow one diagnosis. Problem-oriented records require training and the same problem has to be documented several times, but all documentation I slinked 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 are easier to use, and all information related to patient care is filed together....
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