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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.
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:
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:
Health Literacy
Health literacy is an individual's or a community's capacity to comprehend, receive, read, and use relevant healthcare information and services. The World Health Organization (WHO, 2018) defines health literacy as the cognitive and social skills that determine the ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. As a result, the WHO helps individuals manage long-term health concerns, participate in preventative programs,...
Health Information Technology and Healthcare Information System
Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Accuracy, limits, and approximation
Accuracy, limits, and approximations are common in many fields, especially in engineering calculations. These concepts are imperative for ensuring that a given value is as close as possible to its true value.
Accuracy is defined as the closeness of the measured value to the true or actual value. In engineering mechanics, repeated measurements are taken during theoretical or experimental analyses to ensure that the result is precise and accurate.
The accuracy of any solution is based on the...
Accuracy is defined as the closeness of the measured value to the true or actual value. In engineering mechanics, repeated measurements are taken during theoretical or experimental analyses to ensure that the result is precise and accurate.
The accuracy of any solution is based on the...
Method of Sections
Consider a truss structure, as shown in the figure.
Legal Guidelines for Documentation
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
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No abstract available in PubMed .

