Organizing Medical Records:
One of the most important factors for proper billing and coding starts with the development of a well-documented and organized medical record. This is largely because patients and health care providers are normally faced with the need of keeping and providing medical records. These individuals are usually responsible for providing copies of their medical records to health care specialists and consultants. In most cases, medical records are typically organized in various ways including:
Source-oriented Records:
This is a traditional patient record model that maintains reports depending on the source of documentation with each source of data containing a labeled section known as sectionalized record. In this format, all documents created by the nursing staff are located in record's nursing section, medical section for physician-generated documents, and radiology section for radiology reports (Green & Bowie, 2010, p. 89).
Problem-oriented Records:
This is a more systematic method of documentation that contains four components...
database, problem list, initial plan, and progress notes. The database contains of the least set of data to be gathered on each patient as the problem list contains a list of the patient's problems. While the initial plan outlines the actions to be taken on the patient's condition, the progress note summarizes the patient's treatment, reaction to care, and discharge condition.
Integrated Records:
This patient record format basically involves the strict arrangement of reports in chronological date order. This model facilitates the observation of the patient's progress based on test results and how he/she responds to treatment according to the test results.
Unit Medical Record System:
A unit medical record system is a model that allows for a more comprehensive documentation of medical records since it contains information regarding patient's care such as previous and current medical history and the undergone procedures. In this system, a patient's records are stored in a single file which resides in a central repository and travels with the patient. The…
