Records_Format

Records format is a way that hospitals maintain and follow their records and how hospitals keep up to comply. When a doctor files his records he files them in his or her on filing cabinet that they can go by their patients. When a nurse files records they put those files in the nursing files so that all other nurses can access it as well. When a nurse’s assistant, medical assistant, or administrator files a record they file those records in assigned area where they should be filed to be accessed. When you need to deal the problematic approach of filing the best source is to use the S.O.A.P method. This method is used to detail notes in a patient’s record. When using subjective components patients files to describe in narrative form when it’s the patients first time. Most facilities use mnemonic old charts. The second component is objective; this component identifies the patient’s vital signs, examination, and lab work. The third component the third component is assessment, during this time brief summary of what is going on with the patient is given. The fourth component is called the plan. This give the details of what the provider will do to treat the patient, and what the patient was told to do after the briefing of sitting with the doctor. Patient’s record has its disadvantage and advantages. The oriented forms are located right where originated. It is said to be a problem when hospital employees find it hard to follow the diagnosis. To deal with problem oriented records it is good for the provider to have experience and well trained in the specific area. Every style of record keeping is said to be very time consuming. But without the procedures and steps error is very easy to do. When there is no communication and there is missing understanding this can become a disadvantage. The advantages are knowing where the records are kept and how they are kept.