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 from the physician are placed in the medical section, and reports from radiology can be found 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 chronological order are called integrated records. This type of record-
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This note was uploaded on 08/25/2011 for the course HIS 135 taught by Professor Runyon during the Spring '10 term at University of Phoenix.