HCR 210 week 3 checkpoint

HCR 210 week 3 checkpoint - treatment based on test...

Info iconThis preview shows page 1. Sign up to view the full content.

View Full Document Right Arrow Icon
Source oriented records maintain records according to the source of documentation. The nursing section of the chart generates documents by the nursing staff. The radiology section generates radiology reports and the medical section generates physician documents. 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 is a list of the patient’s problems. The initial plan is the 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 chronological order this allows for observation of how a patient is responding to
Background image of page 1
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: 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....
View Full Document

Ask a homework question - tutors are online