Medical Records Module

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Information about Medical Records Module

Published on September 25, 2017

Author: Niccole.OTA



Types of Medical Records: Types of Medical Records - Slide2: As an OT practitioner, you will need to be able to review patient’s charts in order to obtain information to assist you with providing OT services for the patient. In this module, we will discuss the three types of medical records. Each type is organized in a different way. Once you understand how each is organized you can look at any medical record, determine the type, and easily locate the information you need. Types of Medical Records: Types of Medical Records Medical records, sometimes referred to as charts, may be kept in a variety of formats. The three most common include: problem oriented medical records (POMR) source oriented medical records (SOMR) integrated health records No audio Problem Oriented Medical Records: Problem Oriented Medical Records A POMR is organized essentially by problems (or diagnoses). Each one has a problem number. The chart is divided into 4 sections including: Database: demographics, history, current medical condition, evaluations Problem list : serves as an index to the rest of the record, all notes refer back to the problem number, usually arranged in 5 columns: chronological problem list, date of onset for each problem, action/s taken, outcome, date of outcome Initial plan that addresses each problem Progress notes: SOAP format or narrative SOAP Source Oriented Medical Records: Source Oriented Medical Records SOMR are organized by subject matter or discipline. Subject matter or discipline examples: lab reports, progress notes for OT, progress notes for nursing, etc. Each will have their own section. Progress notes are typically written in narrative format. Each subject or section is in chronological order. Easy to find specific information , however if you wanted all information for a given time period, you would need to look at all the various sections for that time period. Slide6: This page from a medical record only contains nursing notes. This means this medical record is organized by subject or creator (so the RN). This is an example of SOMR. Integrated Health Records: Integrated Health Records Integrated health record are arranged strictly by chronological order, regardless of source, subject or discipline of original information. Provides a good account of continuous information or events as they occur. It can be difficult to find information from just one subject or discipline. Due to this, many facilities have each discipline, source, or subject use a different color of ink to document in. Thus making it easier to find specific records. For example, all OT notes might be in green. So paging through the record each time you see green you would know it is an OT note. To summarize: To summarize POMR are organized by the problems. SOMR are organized by subject or who is writing the note. Integrated records are organized by the date and time the entry is written no matter who writes it.

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