HCR210 record formats Essay Example for Free

HCR210 constitution formats EssaySource orient medical record (SOR), is a traditional patient record format that organizes information about a patients c atomic number 18 according to the source of accompaniment within the record. Patient records are filed under their specific sectionalized areas in chronological order.Many medical facilities use this format. One of the advantages is that it is easy to locate documents. For example, if a physician ineluctably to reference a recent lab report, it croupe easily be found in the science laboratory section of the record. Another advantage is that same source documents can be filed together. Some of the disadvantages of the SOR format is that file reports can be time consuming, several sections within a record need to be created and it can be difficult to follow one diagnosis.The Problem oriented medical record (POR), was developed by Lawrence Weed in an effort to improve the organization of patient records. This format is a mor e overbearing method of documentation, which consists of four components, database problem list initial plan and progress notational systems. The POR record also utilizes the strap structure (subjective, objective, assessment, plan).The database serves as an overview of patient information such as chief complaint, present conditions and diagnoses, social data past, personal, medical, and social history, review of systems, physical examination and baseline laboratory data.The problem list is filed at the scratch of the patient record and serves as a table of contents, containing a list of alone the patients problems. Each problem is numbered, which aids in indexing documentation throughout the record.The initial plan, describes what actions will be taken to learn more about the patients condition according to three categories, symptomatic/management and therapeutic plans as well as patient education.The discharge summary is documented in the progress note section of the POR, an d summarizes patient care, treatment, response and condition. If apatient is transferred, a transfer note is also documented.Some advantages of using the POR are that it is very organized, it facilitates patient treatment and education and that all documentation is linked to specific problem. Some disadvantages are that filing this format is time consuming, it requires specific training and that all data associated with more than one problem must be documented several times.The Integrated record format arranges reports in strict chronological ascertain order or in reverse date order. This format allows for observation of how the patient is progressing and responds to treatment based on and according to test results. Most hospitals unify physician and ancillary progress notes only, requiring progress note entries to be clearly identified by discipline, which of necessity to be identified at the beginning of each progress note, (i.e. dietary).The advantages of using this format is t hat it is easy to use, it is little time consuming to file reports and all information on care is filed together. Some disadvantages of this format are that it is difficult to compare as well as retrieve information from the same discipline.