Parvez Mondal BBA HM

1. Medical Record Formats
By Parvez Mondal
Depertment of Management
3rd Semister
Brainware University

2. What is medical record ?
It is a document containing sufficient data written in sequences of events
to justify the diagnosis,and warrant the treatment given and the end
results.

3. Medical record formats
1.Source oriented medical
record
2.Integrated medical record
3.Problem oriented medical
record

4. Source oriented medical record
The most common paper based management system arranges information in the
medical record according to its source.
Separate forms for nurses, physicians, dietitians, and other health care
professionals to document assessment findings and plan the patient's care.
Narrative charting requires documentation of patient care in chronologic order.

6. Integrated medical record
Integrated medical record files all documents in streak chronological
order,regardless of their source.
Each episode of care is clearly defined by data except laboratory test result.
This method of assessment is used in a limited number of Health Care
institution.

7. Problem oriented medical record
POMR has four basic components-
• Data base
• Problem List
• Initial plans
• Progress notes

8. Progress notes

9. Advantages:-
Disadvantages:-
• Documents care by focusing on patients problems.
• Promotes problem-solving approach to care.
• Result in loss of chronologic chatting.
• More difficult to track trends in patient status.