9.8:
Methods of Documentation I: Source-Oriented Records
Source-oriented records, or SOR, is a type of medical record keeping that organizes patient information by the data source.
This system divides the medical record into sections for each healthcare group, such as nurse's notes, physician's notes, physical therapist's notes, and laboratory reports.
Notations are entered sequentially, with the most recent data at the top of the list.
For instance, if the patient were diagnosed with a fracture, information about this problem would be available in the physician, nurse, and physical therapist records.
The advantages of SOR are that it is organized based on each healthcare provider, so it is easy to understand the patient's history from one provider to the next.
The documentation is clear and concise since each discipline maintains a separate record.
The disadvantages are that SOR can lead to duplication of information in various sections, resulting in unnecessary work and errors.
It is time-consuming because each section requires a separate entry.
Some examples of forms used in a source-oriented record include admission sheets, physician orders, and narrative notes.
9.8:
Methods of Documentation I: Source-Oriented Records
Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
- • Organization by Data Source: Patient information is segregated into sections based on the healthcare provider or department, such as nursing notes, physician notes, and lab results.
- • Sequential Entry: Notations are entered chronologically, with the most recent data at the top of each section.
- • Comprehensive Coverage: Information regarding a specific medical issue may appear in multiple sections, reflecting input from different healthcare providers.
Advantages of Source-oriented records:
- Organization by Author: Entries are organized by healthcare providers, simplifying the tracking of their contributions.
- Familiarity for Providers: Healthcare providers are accustomed to this method, which makes it easier to locate their notes.
- Clear Accountability: SOR helps maintain accountability as each entry is attributed to a specific provider or department.
- Comprehensive and Clear Documentation: This system promotes thorough documentation, motivating providers to accurately record information and procedures.
- Clear Understanding: It is easy to understand the patient's history as it transitions from one provider to another
Disadvantages of Source-oriented records:
- Fragmented View: The information may need to be more cohesive, making it easier to get a holistic view of a patient's medical history or treatment plan without integrating the records.
- Inefficiency: Searching for specific information across multiple entries authored by different providers can take time and effort.
- Duplication: There's a risk of duplication if providers fail to coordinate and inadvertently document the same information multiple times.
- Limited Collaboration: Collaboration among healthcare providers may be hindered if information is siloed based on its source.
- Time-consuming: Each section requires a separate entry, which can be time-consuming.
Types of forms used in source-oriented records can include:
- Progress Notes: These are typically authored by healthcare providers to document patient encounters, including assessments, diagnoses, treatments, and follow-up plans.
- Admission Sheets: Records information collected during the patient's admission to the healthcare facility.
- Physician Orders: Documents physician instructions for patient care and treatment.
- Consultation Reports: Documents detailing consultations with specialists or other healthcare providers, including recommendations and treatment plans.
- Procedure Notes: Notes documenting procedures performed on a patient, including surgical procedures, diagnostic tests, and therapeutic interventions.
- Diagnostic Reports: Reports of diagnostic tests such as imaging studies, laboratory tests, and pathology results.
- Therapy Notes: Documentation of therapy sessions, including progress, interventions, and patient responses.
- Discharge Summaries: Summaries of a patient's hospital stay or treatment episode, including diagnoses, treatments, follow-up recommendations, and discharge instructions.