Record Formats
Lisa Rosier
HCR/220
July 19, 2010
Linda Murray
Records format 2
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 specific 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 college 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 patient 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.
Records format
