SOR Documentation Model
Rabu, 04 Januari 2023
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Definition of SOR Documentation Model
SOR documentation model ( source oriented record)is a source-oriented documentation model. This model can be applied to inpatients, in which there is a doctor's message note written by the doctor, and nursing history written by the nurse. However, in general these notes contain messages from doctors. The records in this model are placed on the basis of the discipline of the person or source that processes the documentation. This SOR documentation model can be made with graphic forms, medication administration formats, nurse record formats including the client's medical history, patient treatment history and progress, laboratory examinations and diagnostic examinations. , hospital admission form and form for surgery signed by the patient and family. The SOR documentation model consists of 5 components, namely:
a. The acceptance sheet contains biodata
b. Doctor's instruction sheet
c. Medical history or disease sheet
d. Nurse's notes
e. Special notes and reports
2. SOR (Source Oriented Record) Documentation Model Format
Source : P : Nurse 's signature and date
D : Doctor
F : Physiotherapist
G : Nutritionist
Date | Time | Source | Progress Note |
Date month Year | Intervention Time | P | 1. Includes assessment, identification of problems, the need for an intervention plan, solving problems, evaluating the effectiveness of interventions, and results. 2. Nurse's signature. |
D | 1. Includes observing the client's condition, evaluating progress, identifying new problems and other solutions, planning interventions, and the latest treatments. 2. Doctor's signature. | ||
F | 1. Includes things that need to be done physiotherapy, client problems, plans, interventions and results. 2. Physiotherapist's signature |
3. Advantages of the SOR ( Source Oriented Record ) Documentation Model
a. Presents sequential and easily defined data
b. Make it easier for nurses to do documentation
c. The documenting process is simplified
4. Disadvantages of the SOR ( Source Oriented Record) Documentation Model
a. Hard to find past data
b. The implementation of nursing care requires a lot of time
c. Requires data analysis from several sources to determine the problem of the intervention that will be given to the client
d. Client development is difficult to monitor
saya hanya seorang individu yang sedang memahami arti dari sebuah kehidupan, belajar akan manis dan pahitnya dunia dan merasakan arti dari sebuah keluarga dan sahabat tentunya seorang kekasih yang kelak akan jadi ibu dari anak-anak saya.
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