9.8 : 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:

• Organization by Data Source: Patient information is segregated into sections based on the healthcare provider or department, such as nursing notes, physician notes, and lab results.
• Sequential Entry: Notations are entered chronologically, with the most recent data at the top of each section.
• Comprehensive Coverage: Information regarding a specific medical issue may appear in multiple sections, reflecting input from different healthcare providers.

Advantages of Source-oriented records:

1. Organization by Author: Entries are organized by healthcare providers, simplifying the tracking of their contributions.
2. Familiarity for Providers: Healthcare providers are accustomed to this method, which makes it easier to locate their notes.
3. Clear Accountability: SOR helps maintain accountability as each entry is attributed to a specific provider or department.
4. Comprehensive and Clear Documentation: This system promotes thorough documentation, motivating providers to accurately record information and procedures.
5. Clear Understanding: It is easy to understand the patient's history as it transitions from one provider to another

Disadvantages of Source-oriented records:

1. Fragmented View: The information may need to be more cohesive, making it easier to get a holistic view of a patient's medical history or treatment plan without integrating the records.
2. Inefficiency: Searching for specific information across multiple entries authored by different providers can take time and effort.
3. Duplication: There's a risk of duplication if providers fail to coordinate and inadvertently document the same information multiple times.
4. Limited Collaboration: Collaboration among healthcare providers may be hindered if information is siloed based on its source.
5. Time-consuming: Each section requires a separate entry, which can be time-consuming.

Types of forms used in source-oriented records can include:

1. Progress Notes: These are typically authored by healthcare providers to document patient encounters, including assessments, diagnoses, treatments, and follow-up plans.
2. Admission Sheets: Records information collected during the patient's admission to the healthcare facility.
3. Physician Orders: Documents physician instructions for patient care and treatment.
4. Consultation Reports: Documents detailing consultations with specialists or other healthcare providers, including recommendations and treatment plans.
5. Procedure Notes: Notes documenting procedures performed on a patient, including surgical procedures, diagnostic tests, and therapeutic interventions.
6. Diagnostic Reports: Reports of diagnostic tests such as imaging studies, laboratory tests, and pathology results.
7. Therapy Notes: Documentation of therapy sessions, including progress, interventions, and patient responses.
8. Discharge Summaries: Summaries of a patient's hospital stay or treatment episode, including diagnoses, treatments, follow-up recommendations, and discharge instructions.