Organizing Medical Records:

One of the most important factors for proper billing and coding starts with the development of a well-documented and organized medical record. This is largely because patients and health care providers are normally faced with the need of keeping and providing medical records. These individuals are usually responsible for providing copies of their medical records to health care specialists and consultants. In most cases, medical records are typically organized in various ways including:

Source-oriented Records:

This is a traditional patient record model that maintains reports depending on the source of documentation with each source of data containing a labeled section known as sectionalized record. In this format, all documents created by the nursing staff are located in record's nursing section, medical section for physician-generated documents, and radiology section for radiology reports (Green & Bowie, 2010, p. 89).

Problem-oriented Records:

This is a more systematic method of documentation...
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