HCR 210 Week 3 Checkpoint - Record Formats

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

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HCR 210 Records Format Source oriented records management is the way hospitals maintain and comply with their records keeping. In such when a Doctor files his records; he files them in the doctors’ records. When a nurse files their record, the nurse files those records in the nurses’ files. When a CNA, CMA or even an administrator files a record those records are also filed in their assigned categories. When dealing with the problematic approach of assessing problem oriented records keeping the acronym S.O.A.P. is used. This is the method of documentation that health care providers use to detail notes in patients records. Subjective components are when the patient’s condition is described in narrative form for the patients first time. Some providers use the mnemonic OLDCHARTS. This is the onset, location, duration, character, alleviating and aggravating factors, radiation temporal pattern, and symptoms associated. The second component is known as Objective component. This is a detail of the patient’s vital signs,
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HCR 210 Week 3 Checkpoint - Record Formats - HCR 210...

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