Paper Health Record Documentation

Paper Health Record Documentation

Some healthcare organizations still utilize the paper-based health records. The paper-based health record can take the source-orientated health record format in which the documentation is organized by source or originating department. For instance, all nursing notes are together, and all the physician progress notes are grouped together. With each source, the health record documentation is placed in reverse chronological order, where the most current or recent documentation is first. Reverse chronological order is kept while the patient is being treated. Many times post patient discharge, the health record is kept in its source orientation, but the documentation in each source section is rearranged and placed in chronological order. Other times, the health record post patient discharge is kept in reverse chronological order; this is called universal chart order.

In an integrated health record, the documentation is placed in chronological order regardless of source. This means that the lab results, nurses’ notes, physician orders, and physician progress notes are placed in the order in which they occurred. The order of the health record is determined by when the documentation was entered into the health record, when the service or treatment was rendered, or when a test result was processed.

The subjective, objective, assessment, plan (SOAP) method is used to construct physician progress notes. Physicians use the acronym SOAP to remember what elements of documentation must be included in a progress note. The SOAP methodology came from the problem-oriented health record developed by Lawrence Reed in the 1970s, which defines and documents clinical problems individually (AAPC 2015). The problem-oriented health record consists of a problem list, the history and physical examination and ­initial lab findings (the database), the initial plan (tests, procedures), and progress notes. The HIM professional must be able to read and understand the documentation structure to locate information needed for coding, audits, and other usages.

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