abnormal findings within Record Formats

Records are kept together by subject matter, for example; lab information are all together in one section, progress notes are all together, xray or laboratory tests are filed under a specific label, and so forth. The problem oriented records (POR) is recording important data about the health status of a patient in a problem-solving system. This data base gathers together all findings relative to a specific problem in the patient’s medical record, so physicians and nurses can share the knowledge of specific problems to plan their course of action that needs to be taken.

It also consists of an initial plan and progress notes in the patient’s record. Problems include anything that requires diagnostic reviews, abnormal findings, and symptoms; also considered as a problem are medical, economic, and financial issues. The initial plan is a strategy that describes what actions should be taken to treat the patient’s issues.

Also used to document problems and notes is a SOAP structure which includes; subjective-a statement about how they feel; objective-observations of the patient; assessment-opinion or evaluation made by the physician; plan-diagnostic, plans to resolve the problems. The integrated medical record (IMR) are reports used in chronological date order. This type of record lets you know how the patient is progressing depending on the test results that were given based on the treatment. Physicians and nurses should be very committed to filling out progress notes.

It is required to provide progress notes and to clearly identify the patient’s health care. The advantages of SOR’s are if a physician needs to reference a patient’s last lab reports, he/she can easily find it in its assigned label “source”. It would be good to label specific sectionalized areas in chronological order. The disadvantages about SOR’s are if records are not placed in its right section, it can be very difficult to put them in its right place which will take some time to do.

The advantage of POR’s is very descriptive and is documented in an organized fashion. It may take some time to get use to this type of medical record. There will probably be times where you might have to write the patient’s problem more than once in the preferred section of the medical record. The advantages of IMR’s are simple to use and is less time-consuming to fill out. The disadvantage about this type of report is it can be difficult to retrieve and compare information if you are not consistent with filling out the progress notes.