Question

1-Describe the similarities and differences between narrative notes, POMRs, SOAP notes, and FOR.

2-Describe the advantages and disadvantages of narrative notes, POMRs, SOAP notes, and FOR.

3-Describe how the FOR and SOAP format can be used together

4-What are the positive and negative aspects of using forms and templates?

5-Why is it important to learn the different documentation formats?

Answer 1

1) •Narrative notes;
Information written in paragraph form. Needs a developed outline. Appropriate for describing a succession of events, describing interactions, conversations with other HC providers. Any situation requiring detailed explanation.

•Problem-Oriented Medical Record (POMR);
Organized according to pt problems. First page-list of pr problems. Each problem should answer 5 questions: Subjective data, Objective data, Impression, Treatment, Plan-treatment plan.

• SOAP;
•Subjective •Objective •Assessment •Plan

Subjective
Anything pt or family says related to their condition. Pt coplaints, home situation, goals.

Objective
Relevant tests and measures. Patient status. Interventions.

Assessment
Clinician's interpretation or impression. Response, changes, progress, explanation, summary, and effects.

Plan
Plan for next treatment, plan for education, new exercises added, frequency, plan for reevaluation or discharge, plan for discussion woth PT.

•Functional Outcomes Reporting (FOR)
Soap note that demonstrates the effect of impairment on functional limitations. Focuses on ability rather than impairments.ucture.
•Difficult to read.
•Difficult to follow problem solving process.

•POMR Advantages;
•Provides organization and structure.
•Includes list of problems.
•Provides a specific plan.
•Allows someone to go straight to a specified problem. •Provides a chronological sequence.
•POMR Disadvantages;
•Difficult for providers to see the "whole pt."
•Very time taking for pt's with multiple problems.

•SOAP Advantages;
•Includes information pertaining to all pt's problems unlike POMR. Widely used.
•Provides structure.
•Provides a logical flow and problem solving.
•SOAP Disadvatages;
•Recorded in terms of impairments.
•Centered around deterioration rather than progress toward improving function.

•FOR Advantages;
•establishes a relationship between the pt's deterioration and abilities.
•Improves read ability for non-health care provider.

3) Change objective from soap notes.
•Clearly and objectively describe pt'a functional status. •Change assessment from soap notes.
•List impaiments being addressed with therapy.
•Describe how betterment that will lead to better activity.

4) Templates and Fill-in Forms
•Assist with time management issues. Paper or computerized. Need blank for narrative comments.

Template and Fill-in Advantages
•Minimize writing, maintain accuracy, consistant.

Template and Fill-in Disadvantages
•Speak and write the documentation. Incomplete documentation.

5) Medical records consist of a patient’s demographic information (name, address, age, gender, etc) as properly as that patient’s medical history, check results, vaccinations, and different clinical history.
Phrases such as medical record, fitness record, and clinical chart are frequently used interchangeably, and these terms encompass the physical or electronic medical document for every patient as properly as all that patients’ medical information.
Historically, medical information have been stored and maintained with the aid of predominant care carriers themselves, however recently a vogue has emerged that sees sufferers taking accountability for the storage and renovation of their very own clinical records.