Experience of coding ambulatory visits to outpatient clinics

K Gibson1, J Ives, M Wilson

  • 1Princess Alexandria Hospital, Brisbane.

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Managed Care System:
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Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
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Key Attributes include the following:
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Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
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Long-Term Care Facilities
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Nursing Clinical Information System (NCIS)
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Critical attributes of NCIS include: