来源导向式记录(SOR)是按照数据源进行组织并保存的医疗记录。来源导向式记录记录的系统最初开发于1900年中期,该系统用来组织医院和其他医疗机构中不断增加的患者数据。
在来源导向式记录中,涉及患者护理的每个学科都会有一个单独的医疗记录部分。这种记录方法可以轻松跟踪患者的病情进展,并确保医疗保健提供者能够获取到最新的信息。
其中的主要特征包括以下内容:
来源导向式记录的优点:
来源导向式记录的缺点:
来源导向式记录中使用的表格类型可以包括:
来自章节 9:
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