Medical record formats

Parvez Mondal BBA HM

1. Medical Record Formats By Parvez Mondal Depertment of Management 3rd Semister Brainware University

2. What is medical record ? It is a document containing sufficient data written in sequences of events to justify the diagnosis,and warrant the treatment given and the end results.

3. Medical record formats

4. Source oriented medical record The most common paper based management system arranges information in the medical record according to its source. Separate forms for nurses, physicians, dietitians, and other health care professionals to document assessment findings and plan the patient's care. Narrative charting requires documentation of patient care in chronologic order.

5. Integrated medical record Integrated medical record files all documents in streak chronological order,regardless of their source. Each episode of care is clearly defined by data except laboratory test result. This method of assessment is used in a limited number of Health Care institution.

6. Problem oriented medical record POMR has four basic components- Data base Problem List Initial plans Progress notes

7. Progress notes

8. Advantages:- Disadvantages:- Documents care by focusing on patients problems. Promotes problem-solving approach to care. Result in loss of chronologic chatting. More difficult to track trends in patient status.