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

Definition of Purpose of the Patient Record Ownership of the patient record Hospital inpatient record Hospital outpatient record Physician office record

Provider Documentation Responsibilities 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

Signature Stamp

Abbreviation List

Development of the Patient Record Date order of patient record reports Outpatient record: handling repeat visits Physician office record: continuity of care

Patient Record Formats Primary and secondary sources of information Source-oriented record (SOR) Problem-oriented record (POR) Integrated record

Patient Record Formats (Continued) Automated record systems Computers in health care Longitudinal patient record Advantages and disadvantages of manual and automated record systems

Archived Records Record retention laws Alternative storage methods Facility retention policy considerations Off-site storage

Patient Record Completion Responsibility Governing board and facility administration Attending physicians and other health care professionals

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