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

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

3. 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

4. Signature Stamp

5. Abbreviation List

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

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

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

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

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

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