Chapter7- HOMI PatientRecord

What 2 goals should the Medical Record Serve?A: 1) it should accurately reflect the course2) should indicate the possible causes of diseasesTime Oriented Medical Record - observations are recorded in a purely chronological orderPatient Centered Medical Record - A single paper chart file for each patientSource Oriented medical record - information organized by how the information was generated from the source, i.e. lab, radiology Problem Oriented Medical record - each problem recored using  SOAP format - requires discipline to follow - Biggest issue: data needs to be recorded several times if applies to more than one problem

Present day medical records are not purely time oriented becuase it prohibits trend analysisMost are Source oriented with chronological sub sections sorting and Problem oriented for documentation. 

Computer based records 

What is the disadvantage of Transcribed notes: Data is not immediately available, and misinterpretation errors

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