Chapter 4

Introduction to the Patient Record

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part

Purpose of the Patient Record

• Ownership of the patient record• Hospital inpatient record• Hospital outpatient record• Physician office record• Alternate care settings

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part

Provider Documentation Responsibilities

• Authentication of patient record entries– Signatures– Countersignatures– Initials– Fax signatures– Electronic signatures– Rubber stamp signatures– Abbreviations used in the patient record– Timeliness of patient record entries– Amending the patient record

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part

Abbreviation List

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Development of the Patient Record

• Inpatient record: Admission to discharge• Date order of patient record reports• Outpatient record: handling repeat visits• Physician office record: continuity of care

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part

Patient Record Formats

• Primary and secondary sources of information

• Source-oriented record (SOR)• Problem-oriented record (POR)• Integrated record• Chief complaint, history, examination,

details,

drugs/dosages, assessment, and return visit

(CHEDDAR)• History physical impression plan (HPIP)

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part

Patient Record Formats (Continued)

• Automated record systems• Computers in health care• Longitudinal patient record• Advantages and disadvantages of manual

and automated record systems

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Archived Records

• Shadow records and independent databases• Record retention laws• Facility retention policy considerations• Alternative storage methods• Off-site storage• Record destruction methods• Disposition of patient records following

facility closure

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part

Patient Record Completion Responsibility

• Governing board and facility administration• Attending physicians and other health care

professionals

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part

Role of the HIM Department in Record Completion

• Record assembly• Quantitative analysis• Qualitative analysis• Concurrent analysis• Statistical analysis