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Methods of Documentation I: Source-Oriented Records

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.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:

Methods of Documentation VII: EMR

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...

Purpose of Health Records I

Purpose of Health Records I

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:

Flow Sheet

Flow Sheet

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:

Methods of Documentation III: PIE

Methods of Documentation III: PIE

Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:

Introduction to Documentation and Reporting

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...

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Related Experiment Video

Updated: Mar 21, 2026

The Multiple Sclerosis Performance Test MSPT: An iPad-Based Disability Assessment Tool

The Multiple Sclerosis Performance Test MSPT: An iPad-Based Disability Assessment Tool

Published on: June 30, 2014

Medical scribes: How do their notes stack up?

Anita D Misra-Hebert¹, Linda Amah², Andrew Rabovsky³

¹Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, OH, USA.

The Journal of Family Practice

|May 10, 2016

Summary

This summary is machine-generated.

Medical scribes

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Area of Science:

Medical Informatics
Clinical Documentation

Background:

Physician burnout is a significant concern, partly due to administrative burdens like note-taking.
Medical scribes are increasingly utilized to alleviate these burdens.

Purpose of the Study:

To compare the overall quality of outpatient clinical notes generated by medical scribes versus physicians.
To evaluate the impact of scribe utilization on documentation quality in specific patient encounters.

Main Methods:

A small, retrospective review of outpatient notes.
Comparative analysis of notes based on quality ratings.
Inclusion of notes from specific patient encounter types.

Main Results:

Scribe-generated notes were rated slightly higher in overall quality compared to physician-generated notes.
Quality differences were observed in certain patient encounter types.

Conclusions:

Medical scribes can produce high-quality outpatient notes.
Scribe utilization shows promise in improving clinical documentation efficiency and quality.