Tag Archives: source-oriented record

Week 3 – Virtual Lab and Record Formats

This week’s assignment was a scavenger hunt in a Virtual Lab. This was the first time, for me, to see what an electronic health record looked like. It was really neat to see! The virtual lab is through AHIMA.

We were given MRNs (medical record numbers) and had to answer questions about the record. Sounds easy enough, however, when you’re unfamiliar with the set up of the electronic record, it can be a little overwhelming at first. After bringing up the record, some of the items we had to search for included: “What is the patient’s Glasgow coma score on 7/31/2006 at 8PM?; On the patient’s Braden assessment, what activities does she do and how often?”

It was a great assignment and I enjoyed it. I’m looking forward to more virtual lab assignments and getting used to electronic health records!

On another note, our discussion board assignment this week was interesting too. Here is my post:

Describe the different formats used for health records in healthcare organizations and the strengths and weaknesses of each.

Paper Records:

Source-Oriented Health Record format – organizes the information according to patient care department that provided the care, or who provided the care. Strength – filing reports would be easy. They would just have to look at where the report came from and date, and file in that section. Weaknesses – It would be difficult to follow a certain course of treatment for the patient, since they would have to search through everything, making it time consuming. Also if a facility has many different departments, there will be even more sections in the record to search through.

Problem-Oriented Health Record format – there is an index list that defines each problem. Everything is itemized and specific problems are organized into four parts. Strength – makes it easier to follow a course of treatment under a specific problem. Weakness – this type would be time consuming as well, especially to file a new problem in it.

Integrated Health Record format – the documentation is arranged in chronological order and can have reports from different sources throughout. Strength – less time consuming and would be very easy to follow a course of diagnosis and treatment for a patient. Weakness – it would be difficult to compare similar data. Like blood glucose tests for a diabetic patient, they could be scattered throughout the record. This could also be time consuming if someone has to pull many reports because it would take time to find them, and then time to put them back in the correct order.

Hybrid Records:  part of the record is stored in a paper file and parts are stored electronically. Strength – used to help transition to electronic based records. Weakness – difficult to locate all the sections of the record, if it isn’t noted somewhere what is still on paper and where it is located.

Electronic Records: electronic record of health-related information and accessed by more than one organization. Strength – unlike a hybrid record, all the information is in one place. Helps with clinical decision making. Accessible by different users in the same organization. Weakness – No standardized guidelines. Can be difficult to change over to.