Differences Among Source Oriented Records, Problem...

1. CheckPoint: Record Formats * Resource: Ch. 4 of Essentials of Health Information Management: Principles and Practices 1. Summarize, in 250 to 300 words, the differences among source oriented records, problem oriented records, and integrated records. 2. Include how you think the advantages and disadvantages of each record format affect everyday work—remember to think about retrieving records as well as filing them. 3. Post your CheckPoint in your Assignment Section as an MS-Word document. Patient Records 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),†¦show more content†¦2. Problem list: The problem list is kept in the front of the record and can be likened to a table of contents in a book. Another conceptual characteristic of the POR is problems are expressed at the level of the writers understanding and do not include diagnostic impressions which are considered as part of the treatment plan. 3. Initial Plan: Development of a care plan The initial plan should be considered in 3 parts: I. Diagnostic (Dx) that is plans for collecting more information II. Therapeutic (Rx) plans for treatment and, III. Patient Education plans for informing the patient as to what is to be done. 4. Progress notes: Should indicate what has happened to the patient, what is planned for the patient, and how the patient is responding to therapy. Progress notes should contain four component parts: I. Subjective part written in the patients own words about his problem II. Objective part the doctors observation and test results. III. Assessment is the diagnostic opinion of the health care provider IV. Plan for continued treatment. Contains diagnostic and therapeutic and educational plans to resolve the problem. In PORs, eachShow MoreRelatedData Warehousing : A Data Warehouse1151 Words   |  5 Pagescreating reports. Data warehousing system is used for decision making by analyzing the reports. A data warehouse is a relational database, which is designed for analysis and query. It helps an organization to consolidate and analyze data from different sources and make decision. 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