TYPES OF MEDICAL RECORDS

Ms. Priyanka Roy Chowdhury. Asst. Prof.

St. John’s Medical College
TYPES OF MEDICAL RECORDS

 Source Oriented Medical Records

 Integrated Medical Records

 Problem Oriented Medical Records

Source Oriented Medical Records
 This conventional method of arrangement is in use in the
majority of Hospitals.

 The record is divided in sections such as Physicians notes,

Laboratory reports, Nursing notes, and so forth.

 Within each section entries are arranged in chronological

order.

 Each section must be reviewed to obtain a complete

impression of the patient's care and treatment.
Example
 Source-oriented- MR allows each medical specialty
to chart its findings in its own section
 Eg: Physicians chart their notes on the physicians
progress notes, nurses chart on the nurses note
section physical or respiratory therapist chart on
physical therapy notes
Advantages and Disadvantages
 Easy and fast to record

 Flexible

 Omitting information is highly possible

 Difficult to assess information

Problem Oriented Medical Records

 A method of recording data about the health system,

in a problem solving system
 In an easily accessible way that encourages ongoing
assessment
 And revision of the healthcare plan by every
stakeholder in the healthcare team
 Comprehensive approach by Dr.Lawrence Weed in
the late 1950s
Core Components
 Data Base

 Complete Problem List

 Initial Plans

 Daily Progress Notes

 Final Progress Notes or Discharge Summary

Database
 History of present illness

 Past medical and surgical history

 Social history

 Patient Profile

 Investigation reports
Problem List
 Past Problem

 Present Problem

 Possible or Potential future Problem

 Problems to be categorised as either active or inactive

 Once a number is used in a problem list it can not be

used again
Initial Plan
 Plans for the collection of the data to establish or
facilitate management of stated problems.

 Plans for treatment with mention of specific procedure

or drug

 Plans for patient education concerning his or her illness

and his or her roles in the care process
Progress Notes

 Most Crucial

 Progress Notes chronicle the actions and results of

the plans for each problem listed

 Part of progress notes are known by the acronym

SOAP
SOAP
 Subjective: The Patient’s statement of complaint

 Objective: Physical or Diagnostic Information which is

observable or measurable

 Assessment: Impression, Interpretation, appraisal( without a

good assessment a good plan can not be formulated)

 Plan: Treatments and therapies as well as significant

modifications of treatments and therapies with careful
reference to the appropriate progress notes
Example
Patient Care Plan

Date Prob No. Information Start End Date

Collection/ Date
treatment/
education
goals
 Example
Problem List

Problem No Date Noted Active Inactive

Problem Problem
Advantage
 It makes patient data more useful by noting all problems.

 It allows Physicians to logically direct the healthcare team

 It assures better communication between all members of

healthcare team

 It brings all patient problems into focus and indicates all

treatment problems
Disadvantage
 Insufficient time allotted to provide care to each
patient

 Insufficient financial incentive

INTEGRATED MEDICAL RECORDS

 This method of arrangement is used in a limited number

of health care institutions.
 Integrated Medical Records are arranged in strict
chronological order, regardless of the source of the
original information.
 Thus a Physician's order may be followed by a
consultation report or by a nursing note.
 This type of format provides a good account of the
sequence of events but renders difficulty in the
comparison and contrasting of patient care information.