Approach to The

Nursing Documentation
Model
GROUP 4 :
1.
Approach to the nursing documentation
model :
A. Source Oriented Record (SOR)
B. Problem Oriented Record (POR)
C. Progress Oriented Record (POR)
A. Source Oriented Record (SOR)

1. Definition
Model documentation system is oriented on the source of the information. This
documentation allows each team member to make their own health from
observational results. The results of these studies were collected into one. Each
Member can carry out professional activities independently without depending
on other health team.
This model puts a record on the basis of the discipline of a person or resource
that manages the recording. Part of the reception of the client has its own field
sheets, doctors using the sheet instruction sheets, to record the history of
disease and disease progression, nurses use the nursing notes, as well as other
disciplines have a record each.
2. Source Oriented Records Component :
• Acceptance sheet contains
background information.
• Records of doctors.
• Medical/illness history.
• The nurse's notes.
• Notes and special reports.
• The form charts.
• Form of the drug.
• Form of records of nurses.
• History of
disease/treatment/examination.
• Development of the patient.
• The examination form lab, x-ray, etc.
• The hospital sign-in Form.
• Form for operations that are signed by
the patient/family.
3. An example of the form of the SOR
Date Time Source Note developments
Date/month/years Time action N • Include:
(1) assessment,
(2) identification of the problem,
(3) the need for a plan of action,
(4) the plan immediately,
(5) intervention,
(6) problem solving,
(7) evaluation of the effectiveness actions, and
(8) results.
• Signature of nurses.

D • Includes observations of the State of the pati

ent, the
evaluation of progress, the identification of new
issues and
other settlement, plan of action and the latest t
reatments.
• Signature of doctor.

P • Includes things to do physiotherapy, problem

patients,
planning, interventions, and outcomes.
• signature physiotherapist.
B. Problem Oriented Record (POR)

POR is the development of the SOR documentation model. POR is an effective

tool for documenting a client-oriented health care system. This documentation
model leads to the ideas and thoughts of each team member, so that team
members can express their views in providing health services to clients. This
model facilitates teams in health planning actions and in communication
between team members.
This model concentrates client data, documented and then arranged according
to the problems experienced by the client. This model integrates all data on
client problems collected by doctors, nurses and other health workers involved.
The emphasis is not on who provides health services, but on the issue of what
nursing care is given to clients.
The POR documentation model consists of four components :
1) Basic Data
Basic data is data obtained from the results of assessment when the
patient first entered the hospital.
2) List of Problems
A list of problems containing data that has been identified from basic data
that is categorized as a problem. The problem data is arranged chronologically
according to the results of identification of priority problems. Example:
Date List of problems Person who
discovered problem
1 mr. Andi experiences cva which Dr. doel
results in right hemiplegia and is
weak on the right side, the face is
not symmetrical
3). Preliminary List of Care Plans
The nursing care plan is organized based on the priority list and written in the
nursing care plan. When there is a collaboration action, the doctor will write
down the instructions on the medical record, then translate it by the nurse to
write it down on the treatment plan.
4) Progress Notes (Progress Notes)
Developmental notes contain about the progress experienced by the client on
every health problem experiences. Each health team involved in caring for the
client provides the report on the same progress sheet, arranged according to
their respective professionals.
Continue
 Here are some progress notes that can be used, among others:
1) SOAP (Subjective data, data objectives, analysis / assessment and plan)
2) SOAPIER (SOAP plus Intervention, Evaluation and Revision)
3) PIE (Problem - Intervention - Evaluation)
 Nurse records must be written by nurses every 24 hours, nursing documentation contains
information about:
1) Assessment
2) Independent nursing interventions
3) Collaborative nursing interventions / doctor's instructions
4) Evaluate the success of each nursing action
5) Actions taken by doctors but affect nursing actions
6) Visit of various health teams for example; visite doctor, social worker and others.
C. Progress Oriented Record (POR)
The POR (progress-oriented-record) documentation model is a documentation
model that is oriented towards the development and progress of the client.
 Types of records that can be used in progress oriented record (POR) :
1) Assessment of one or more nursing staff about the condition of the client.
2) Independent nursing care.
3) Nursing care that is delegating.
4) Evaluate the success of each nursing care.
5) The actions taken by the doctor, which affect nursing care.
6) Visit of various members of the health team.
Continue
 Groove sheets, including:  The things that are needed in
recording a client's return are:
a) The results of observations made by
nurses, measurements made a) Health problems that still occur.
repeatedly, and which do not need
to be written narratively. b) Last treatment.

b) Clinic records, fluid balance records c) Handling that still has to be

in 24 hours, treatment notes and continued.
diaries about nursing care. d) Eating habits and rest.
e) The ability for self care.
f) Pattern or lifestyle.
Continue
 Information for health professionals who will  Information for clients, including:
continue further client care includes:
a) A description of the nursing intervention
that will be given to the client.
b) Description of information that has been
submitted to the client.
c) Description of the client's condition.
d) Explanation of the challenges of family
involvement in nursing care.
e) A description of the resources needed at
home.
a) The use of clear and easy to understand
language.
b) Explanation of certain procedures
according to what the client needs.
c) Identify preventive actions that need to be
followed or implemented by clients when
carrying out independent nursing care.
d) Examination of signs and symptoms of
complications that need to be reported by
clients if experienced by clients later.
e) Giving a list of names and telephone
numbers of health workers who can be
contacted by clients.