Running head: MEDICAL RECORDS MANAGEMENT
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MEDICAL RECORDS MANAGEMENT
Hashim MuhammedQasim
Bryant and Stratton College
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There are certain file sizes that are require to file a certain kind of patients’ record such as
lab information, x-ray results, allergies, medication list, health history, referral form,
immunization, hospitalization and emergency visits as well as chart notes. These confidential
information are store in annual medical record and if EMR software used there are certain
program that require to store specific files. (Class Discussion, 2015)
The source-oriented medical record (SOMR) holds information patients lab work,
examination, providers note pertaining to patient’s symptom and other sources as well. The
problem-oriented medical record (POMR) and source-oriented medical record (SOMR) they
both use SOAP or SOAPER to pursue their information about a patient. (SOMR) simply adds
information about a patient in EMR software, this makes the staff’s accessible to patient’s chart
fast and easy. However the problem-oriented medical record (POMR) lists problems pertaining
to the patients chart such as allergies that a patient has, vital data, immunization, medication and
other problems that relates to the symptom that a patient occur. The (POMR) keeps the history of
patient to allow the provider go back to the first symptom the patient had. As it was discussed in
the (SOMR) the (POMR) fallows the protocol of the (SOAPER) again to have the patient
treatment in done properly. The (POMR) EMR used more commonly in a family physician’s
practice and the specialist. Because they record every problem that a patient chief complains
about they use the SOAP note to treat their patient in chronologic order. (Dalh, al et. 2014.
P.300)
The SOAP method of documentation is used for to chart patients’ symptoms in
chronologic order to get more information about the patient that provider can have a better idea
of the symptom that a patient is having. For example:
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S. Subjective, a patient tells the provider how he/she feel, chief complain.
O. Objective, testing, vitals or clinical evidence.
A. Assessment, diagnosis, what are the symptoms a patient is having.
P. Plan, treatment, what procedures are going to be done.
There is SOAP and SOAPER The ER is added to educate the patient about their symptom he/she
was having, this helps the patient for have their medication taken in time from preventing to have
their symptom back again. (Dalh, al et. 2014. P.300)
There are “three major filling systems are commonly used in the ambulatory care setting:
The alphabetic, numeric and subject.” The alphabetic order is used for almost in every hospital
or facility. The alphabetic order makes everything easy in pertaining to hard copy material, the
staff can look up a name by alphabetic order it can be found in seconds. The numeric and
subject can be applied in same order as alphabetically. Numeric version is used in other facilities
besides medical practices, for sample: in a court system it’s used by case numbers in order. There
are other filling systems are used in a medical practice; coloring coding. Coloring coding helps to
recognize a missed placed file in a wrong shelve. (Dalh, al et. 2014. P.306)
There are three kinds of cabinet that are required for a medical office, these equipment
helps any office to have easy access to the files easily and protect confidentiality. The medical
office uses colors as well as alphabetic order to find a patients chart. The vertical filling cabinet
is use for to protect confidentiality of a patient and is usually locked, as other filling cabinet such
as open-shelve cabinet is easy to access and faster than the vertical cabinet. The open-shelve
cabinet usually use colors to specific alphabet to define a letter quick. And the movable filling
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unit is mostly use to store large files, it is usually require physical movement to get to the file or
other mechanical object relate to the unit to help the unit move easier. (Dalh, al et. 2014. P.301)
To maintain medical record safe from the wrong party, the medical administrative assistant
should have an extra screen on the computer monitor to keep the patients’ information
confidential, the most risk a medical practice faces their system being hacked by hacker. This
results to loss medical record stolen and it can cause a patient identity be stolen as well. The
other disadvantage of EMR, that computers can crush anytime due to wrong use or other
software malfunction. For this reason the facility should have a back-up system to have all their
data safe and secure. The advantage of EMR computers are faster than hand writing or searching
in a filing cabinet. As we talked about the (POMR) and (SOMR) data entry can be easy to access
any patients’ document and it easy to have patients record in chronologic order. (Micro, MD.
Nd)
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References
Lindh, W. Q, Pooler, M. S, Tamparo, C. D, Dalh, B. M. Morris, J. A. (2014). Medical Assisting
Administrative and Clinical Competencies. Delmar. Maxwell Clifton Park, NY
Washington, M, P (2015). AHLT 245 Medical Office Procedures: chapter 14
Schein, H (nd). Micro MD. Advantages of Electronic Medical Records
Retrieved from: http://www.micromd.com/emr/advantages.html