Title: Reading: (CU1 M4) Types of Charting - SOMR
Course: SkillsCom CMA 111 16.0 > Section: Credit Unit 1 Module 4

A Source-oriented medical record (SOMR) is a type of charting done in which each healthcare group keeps data on its own separate form. There are sections designed for nurses, physicians, lab, x-ray, etc.  One major advantage of this type of charting is that each discipline can easily find and chart pertinent data.  One major disadvantage of this type of charting is that charting fragments data which makes it difficult to track problems chronologically with input from different groups of professionals.

- This more traditional format divides the actual physical chart with tabs into specific sections which can include the following: History and Physical, Progress Notes (notes that track the patient’s progress), Nursing/Medical Assisting Notes, Laboratory, and Diagnostic Testing.
- The “source” or individual providing the data enters the information within the appropriate section of the chart.
- There is no systematic cross-referencing of data from one section to the next. Progress notes/physician notes are usually recorded in a narrative format, making it necessary to read the entire progress note before determining what is wrong with the patient.
- All reports and notes are kept in reverse chronological order, meaning the most recent note is on top.

Typically this type of charting is mostly restricted to paper charts and/or is used  in acute/skilled care facilities such as hospitals and skilled nursing facilities.

Furthermore, this type of charting has limited value in the Electronic Medical Record.