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

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 doctor’s office

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

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.

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

Patient Record Formats (Cont’d) 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

Patient Record Formats (Cont’d) 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 patient’s health care encounters. Although medical technology is moving towards automated record systems; there are advantages and disadvantages of both manual and automated record systems

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

Patient Record Completion Responsibility Responsibility for completing the patient record resides with the following individuals and should be outlined in the facility’s policies and procedures:  Governing board and facility administration  Attending physicians and other health care professionals  HIM Professionals

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

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