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Dr. Davidson
Dr. Davidson, Board Certified Physician
Category: Medical
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Experience:  Board Certified Specialist in Allergy, Asthma and Immunology
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How do you think the advantages and disadvantages of each records

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How do you think the advantages and disadvantages of each records format effect everyday work. 1.source oriented records 2.problem oriented records 3. integrated records
Hi there, and thanks for your question.

In a problem oriented medical record, the record is kept together by problem number, where a number is XXXXX to each problem. This is the traditional way that most physicians document their records, both in training and in practice. Progress notes in these records are kept in SOAP format. S=subjective (chief complaint, history of present illness), O=objective (physical exam, labs), A=assessment (diagnosis, prognosis), P=plan (treatment).

The major advantages to this record format is the ease of progression through the data. It's organized into stratified sections, and one can quickly find the infomation they need. It also allows for a quick review of multiple visits over time when reviewing past medical records.

In a source oriented medical record, the record is kept together by subject matter (labs are all together, progress notes are all together). Progress notes in a source oriented medical record are written in paragraph format.

Personally I don't see any major advantages to this method. I suppose with the labs all in one area, it's easier to review these data. However, it's easier to review large blocks of numbers vs. large blocks of paragraphed information. Writing the progress notes in paragraph format, without distinct stratified sections makes things more tedious.

Integrated records are a combination of the two other options, source and problem oriented records. I believe it's simple to choose one or the other option, and combining the two just makes things even more difficult.

I hope this information clears up any confusion for you. If you have additional questions please let me know. Otherwise, if you could please click "ACCEPT" on my behalf, I'd greatly appreciate it. That way, I get credit for my work.

Dr. Davidson
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