Record Formats CheckPoint Kelly Schwebel

Record Formats CheckPoint Kelly Schwebel - have the...

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Running head: RECORD FORMATS 1 Record Formats Kelly Schwebel HCR 210 August 12, 2011 Lenora Mathews
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RECORD FORMATS 2 Record Formats Nursing staff will generate documents that will be kept in each patients chart. Each document is source-oriented. For example physician reports are in the medical section and radiology reports would be in the radiology section. Any chart filled out by the nurse is in the nursing section. There are four components that make up a patients chart. Database, list of symptoms or health issues, plans to heal or fix problem and notes on how the patient is progressing. In the database there is an overview of the patient’s information, while there problems is in the symptoms or health issues section. The initial plan is the outline of actions the doctor wants to take to determine the condition of the patient along with the treatment. The progress notes would
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Unformatted text preview: have the patients discharge summary and details of the patients care, treatment, and response to treatment. Integrated records are in chronological order. This is a good way of record keeping so doctors can track how a patient responds to any treatment based on results from tests. There are advantages and disadvantages to all record keeping. For source-oriented records, the information is easy to locate but medical staff may have difficulty following one diagnosis. Problem-oriented records require training and the same problems is often documented several times. With both of these styles filling can be time consuming. When you have an integrated system for record keeping the retrieval if information on a patient is much easier, and filing is less time-consuming....
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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.

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Record Formats CheckPoint Kelly Schwebel - have the...

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