Records format 1

Record Formats

Lisa Rosier

HCR/220

July 19, 2010

Linda Murray
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Medical records offer medical professionals a look into a patient’s medical and personal history. This is

why it is very important for the medical record to be kept in an easily understandable order.

One way to do this is a source oriented problem (SOP) format. This type of file is maintained "according

to the source of the documentation " (Axia college week three readings-Source oriented records (2010)

para.1. For example, if a patient has an x-ray, the results from this scan would be in the radiology section

of the patients’ medical record. The advantages of this type of format would be the ease locating specif-

ic orders or tests, but if the orders or tests aren't properly placed, this would cause delay because the

needed paperwork would not be in the proper location.

Records are also kept in a format called problem oriented record (POR). This format “contains four

components” .These components are database, problem list. Initial plan and progress notes. (Axia col-

lege week three readings-Source oriented records (2010) para.1.The database section contains personal

information as well as medical history. The problem list contains a numbered list of each issue the pa-

tient has. For example-

1. Headaches

2. Blurred vision

3. Confusion

The initial plan section will contain the steps that will be taken to treat the patient. For example, C.T

scans of the head to rule out brain involvement.

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An integrated record is another format used for medical records. This format arranges a patient’s record

in “ chronological date order “Axia college week three reading (2010).para1. This format allows the

medical staff to see how a patient is progressing with treatment. For example,

9-3-xxxx-9:00 a.m. -patient is restless and irritated

9-3-xxxx-2:00 p.m. - Patient resting comfortably, much calmer

An advantage to this format is that it would be easier to file records in chronological order, but it also

makes it harder to view and compare information. If a doctor wanted to view labs taken on the admis-

sion date with labs taken a week after admission, he or she would have to locate the lab results from the

admission date farther back in the file.

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REFERENCES

Axia College. (2010) week three materials. Retrieved from HCR/220-Claims preparation 1: Clean bills of

health course website.