Hcr_210_Week_3_Record_Format

Many facilities and physician offices maintain patient records in a paper format known as a manual record. A variety of formats are used to maintain manual records, including the source oriented records (SOR), problem oriented records (POR), and integrated records. In a source oriented medical record (SOR), the information about a patient's care and illness is organized according to the source of the information within the record, that is, if it is recorded by the physician, the nurse, or data collected from an x-ray or laboratory test are filed under their specific sectionalized areas in the chart usually in chronological order. Many facilities use this format since it is easy to locate documents. For example, if a physician needs to reference a recent lab report, it can easily be found in the laboratory section of the record. However, if a physician wanted to reference all information about a particular diagnosis being treated or treatment given on a particular day, many sections of the record would have to be referenced making it difficult to amass all the information for that specific diagnosis difficult. For PORs, we will define problem as anything that interferes with the health, well being and quality of life of an individual, that may be medical, surgical, obstetric, social or psychiatric, the problem oriented medical record (POR) has four parts: The problem oriented record (POR) or problem oriented medical record is a more systematic method of documentation, which consists of four components: Database, Problem list, Initial plan, and Progress notes. The database contains a minimum set of data to be collected on every patient, such as chief complaint: present conditions and diagnoses, social data, pat, personal, medical, and social history, review of systems, physical examination, and baseline laboratory data. The database serves as an overview of patient information. The problem list acts as a table of contents for the patient record because it is filed at the beginning of the record and contains a list of the patient’s problems. Each problem is numbered, which helps to index documentation throughout the record. Problems include anything that requires diagnostic review or health care intervention and management, such as past and present social, medical, psychiatric.