Records Formats Checkpoint

Records Formats Checkpoint - patient is progressing...

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In this week’s assignment we were asked to summarize the differences between source oriented records, problem oriented records, and integrated records. In source oriented records the records have to be kept and they have to be kept together by subject matter. That means that all of the progress notes that are kept has to together, the labs are all kept together. All of the progress notes are written in paragraph form. In a problem oriented record, the record is kept together by a problem number and a number is assigned to each problem. When the progress notes are kept they are kept in SOAP S= Subjective, present illness and the patients complaint) O=objective (labs and physical exams) A=assessment (these are the diagnosis and prognosis) P= Plan (this is treatment). Integrated records they normally put the repots in chronological order or the record could also be arranged in reverse date order. When this format is used it tells how the
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Unformatted text preview: patient is progressing according to tests results and how the patient is responding to treatment based on the patients test results. In the source oriented records I think that this format affects everyday work by filing the same sources together and this makes it very difficult for someone to follow the diagnosis that has been written and not to mention they are very time consuming. In the problem oriented records all of the problems are linked to one specific problem and it is very organized. It requires much training filing the reports are very time consuming. In integrated records they are easy to use, and they are less time consuming to file. The information is very difficult to get from the same discipline and difficult to compare the same information. I think some of this would be very confusing for someone and could get them in a lot of trouble if they do not pay attention....
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Records Formats Checkpoint - patient is progressing...

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