Chapter 4: The Patient Record: Hospital, Physician Office, and Alternate Care Settings

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Chapter 4 The Patient Record Hospital,
Physician Office, and Alternate Care Settings
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Definition of Purpose of the Patient Record

• Ownership of the patient record The medical
  record is the property of the health care
  facility but the patient has the right to access
  its contents
• Hospital inpatient record - Documents the care
  and treatment of a patient admitted to the
  hospital
• Hospital outpatient record - Documents the care
  and treatment of a patient treated on an
  outpatient basis
• Physician office record - documents the care
  provided in the doctors office

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Provider Documentation Responsibilities

• All patient record entries require authentication
  by
• the author.
• JCAHO requires that only authorized individuals
  may
• make entries in the medical record
• Authentication of patient record entries
• Signatures
• Countersignatures
• Initials
• Fax signatures
• Rubber stamp signatures
• Abbreviations used in the patient record
• Timeliness of patient record entries
• Amending the patient record

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Development of the Patient Record

• Patient records are developed from many sources
  depending on the type of services performed
• Date order of patient record reports - Can be
  chronological or reverse chronological order
• Outpatient record handling repeat visits - In
  the outpatient setting these records are
  retrieved more frequently
• Physician office record continuity of care -
• Provides documentation for continuity of
  patient care. Because of the type of services
  perform these records are accessed more
  frequently due to patient undergoing annual
  physical, acute treatment, visits for
  prescription refills, etc.

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Patient Record Formats

• Many facilities and physician offices still
  maintain records in a paper format known as a
  manual record.
• Primary source of information - Records that
  document patient care by the health care
  professionals e.g. original patient record
• Secondary source of information - Information
  that is abstracted from the original patient
  record (primary source)
• Source oriented record (SOR) - Maintains reports
  according to the source of documentation

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Patient Record Formats (Contd)

• Problem oriented record (POR) - Developed by
  Lawrence Weed document reports according to the
  problem and consists of four components
• Database
• Problem list
• Initial Plan
• Progress notes
• Integrated record - Uses strict chronological
  date order

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Patient Record Formats (Contd)

• Computers in health care
• Electronic health record (EHR) or computer based
  patient record will provide faster access to
  health information and will have the ability to
  link health information created at different
  locations according to the patient identifier.
• Will ultimately replace paper-based records to
  provide timely access to health information for
  health care delivery
• Longitudinal patient record - This EHR contains
  records from different episode of care,
  providers, and facilities that are linked to
  different patients health care encounters.
• Although medical technology is moving towards
  automated
• record systems there are advantages and
  disadvantages of
• both manual and automated record systems

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Archived Records

• Federal and state laws mandate the
• minimum periods that records must
• be retained.
• Record retention laws
• Alternative storage methods
• Facility retention policy considerations
• Off-site storage

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Patient Record Completion Responsibility

• Responsibility for completing the patient
• record resides with the following individuals
• and should be outlined in the facilitys
• policies and procedures
• Governing board and facility administration
• Attending physicians and other health care
  professionals
• HIM Professionals

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Health Information Department

• Cancer registry
• Coding and abstracting
• Image processing
• Incomplete record processing
• Medical transcription
• Record circulation
• Release of information processing

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Role of the HIM Department in Record Completion

• Record assembly
• Quantitative analysis
• Qualitative analysis
• Concurrent analysis
• Statistical analysis

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Reading

• The reading assigned in this unit is Chapter 4
  from the textbook. This chapter discusses the
  documents in an acute care chart and the elements
  needed on each document.

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Discussion

• Please respond to the discussion topic and then
  review and respond to two of your classmates.
• Discuss the illnesses and conditions that are
  acute care and the documents needed in the chart
  that would correspond to those diagnoses.

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HW Assignment

• Complete exercises 1, 2 and 3 in the reading text
  for Chapter 415 points
• Lab assignment from the lab manual 4-1   5 points
  
• Quiz 2 is completed in this unit
• The term project is to be worked on in this unit

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Quiz

• Unit 3 Quiz is on chapter 4 of your textbook

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Questions