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

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... make entries in the medical record Authentication of patient record entries Signatures Countersignatures Initials Fax signatures Rubber ... Concurrent analysis ... – PowerPoint PPT presentation

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


1
Chapter 4 The Patient Record Hospital,
Physician Office, and Alternate Care Settings
2
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

3
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

4
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.

5
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

6
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

7
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

8
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

9
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

10
Health Information Department
  • Cancer registry
  • Coding and abstracting
  • Image processing
  • Incomplete record processing
  • Medical transcription
  • Record circulation
  • Release of information processing

11
Role of the HIM Department in Record Completion
  • Record assembly
  • Quantitative analysis
  • Qualitative analysis
  • Concurrent analysis
  • Statistical analysis

12
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.

13
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.

14
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

15
Quiz
  • Unit 3 Quiz is on chapter 4 of your textbook

16
Questions
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