HCR210 record formats
HCR210 record formats
Source oriented medical record (SOR), is a traditional patient record format that organizes information about a patient’s care according to the “source” of documentation 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 needs to reference a recent lab report, it can easily be found in the 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 filing 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 more systematic method of documentation, which consists of four components, database; problem list; initial plan and progress notes. The POR record also utilizes the SOAP 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 beginning of the patient record and serves as a table of contents, containing a list of all the patient’s 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 patient’s condition according to three categories, diagnostic/management and therapeutic plans as well as patient education.
The discharge summary is documented in the progress note section of the POR, and summarizes patient care, treatment, response and condition. If a
patient 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 date 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 integrate physician and ancillary progress notes only, requiring progress note entries to be clearly identified by discipline, which needs to be identified at the beginning of each progress note, (i.e. dietary).
The advantages of using this format is that it is easy to use, it is less 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.