9.8 : 来源导向式记录

Source-oriented records, or SOR, is a type of medical record keeping that organizes patient information by the data source.

This system divides the medical record into sections for each healthcare group, such as nurse's notes, physician's notes, physical therapist's notes, and laboratory reports.

Notations are entered sequentially, with the most recent data at the top of the list.

For instance, if the patient were diagnosed with a fracture, information about this problem would be available in the physician, nurse, and physical therapist records.

The advantages of SOR are that it is organized based on each healthcare provider, so it is easy to understand the patient's history from one provider to the next.

The documentation is clear and concise since each discipline maintains a separate record.

The disadvantages are that SOR can lead to duplication of information in various sections, resulting in unnecessary work and errors.

It is time-consuming because each section requires a separate entry.

Some examples of forms used in a source-oriented record include admission sheets, physician orders, and narrative notes.