NURSING DOCUMENTATION STUDY MATERIAL
100% VERIFIED CORRECT!
source oriented medical records are commonly used where
patients in hospitals and long-term care facilities
source oriented records usually include:
-admission data
-advance directives
-history and physical
-providers orders: prescriptions, treatments
-diagnostic studies:
-lab data:
-graphic data: intake/output records, vital sign flow sheets, etc
-rehab and therapy notes
-discharge planning
advantages of source oriented records
can easily locate the care provided by each discipline and the results of lab and diagnostic tests
disadvantage of source oriented records
data may be fragmented and scattered throughout the chart; need to review all sections of the
medical record to fully understand clients condition and care
problem oriented medical records are organized around
, the patients problems
problem oriented medical records consist of what 4 parts
database
problem list
plan of care
progress notes
database of problem oriented record systems
demographic data, history, physical, nursing assessment data, and family/social history
problem list of problem oriented record systems
concise listing of problems from the database; once a problem is resolved or if a problem
changes it is listed in problem list.
plan of care in problem oriented record system
includes PCP prescription and the nursing care plan to address the identified problems
progress notes in problem oriented record systems
organized according to the problem list
each discipline charts on shared notes
charting is labeling according to the problems
advantages of problem oriented record systems
100% VERIFIED CORRECT!
source oriented medical records are commonly used where
patients in hospitals and long-term care facilities
source oriented records usually include:
-admission data
-advance directives
-history and physical
-providers orders: prescriptions, treatments
-diagnostic studies:
-lab data:
-graphic data: intake/output records, vital sign flow sheets, etc
-rehab and therapy notes
-discharge planning
advantages of source oriented records
can easily locate the care provided by each discipline and the results of lab and diagnostic tests
disadvantage of source oriented records
data may be fragmented and scattered throughout the chart; need to review all sections of the
medical record to fully understand clients condition and care
problem oriented medical records are organized around
, the patients problems
problem oriented medical records consist of what 4 parts
database
problem list
plan of care
progress notes
database of problem oriented record systems
demographic data, history, physical, nursing assessment data, and family/social history
problem list of problem oriented record systems
concise listing of problems from the database; once a problem is resolved or if a problem
changes it is listed in problem list.
plan of care in problem oriented record system
includes PCP prescription and the nursing care plan to address the identified problems
progress notes in problem oriented record systems
organized according to the problem list
each discipline charts on shared notes
charting is labeling according to the problems
advantages of problem oriented record systems
