Chapter 6 Content of the Patient Record: Inpatient, Outpatient, and Physician Office Records

General Documentation Issues Patient identification Facility identification Addressograph Dating and timing patient record entries

Face Sheet Identification/demographic data Financial data Clinical data

Additional Patient Record Forms Advance directives Informed consents Patient property form Certificate of death

DNR Advance Directive Consent Form

Hospital Inpatient Records: Clinical Data Emergency record Discharge summary/clinical résumé History and physical examination Consultation report Physician orders Progress notes Anesthesia record

Hospital Inpatient Records: Clinical Data (Continued) Operative record Pathology report Recovery room record Ancillary reports Nursing documentation Special reports Autopsy reports

Hospital Outpatient Record Short stay record Uniform Ambulatory Care Data Set (UACDS) Outpatient visit Encounter Ancillary service unit/occasion of service

Physician Office Record Patient registration form Problem list Medication list Progress notes Ancillary reports Encounter form, superbill, or fee slip

Forms Control and Design Forms committee or patient record committee Role of committee Facilitate efficient use of patient record Streamline the forms approval process Ensure documentation is compliant Enhance quality of documentation