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The key to proper billing and coding begins with a well-documented and organized medical record. Typically, medical records are organized in one of three ways. These ways include the following: source-oriented records, integrated progress note records, and problem-oriented records.

Define the main ways each type of records is organized, and describe the typical things that are found in each section. Explain why there are several ways to organize the records.

Part 2: A unit medical record system allows for a more detailed and comprehensive medical record. This record contains information that may be relevant to the patient's care. This includes past and current medical history and procedures undergone.

Answer the following questions:

  • What are the advantages and disadvantages of using such a record system? Give an example of each circumstance.

•Do you feel this is an effective way to organize medical information? Why or why not

 

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