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

2. 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
The patient has a right to request a copy of his/her Medical Record regardless of the type of service performed. Per HIPAA
Guidelines, the patient also has a right to formally request changes/corrections to medical information in his/her Medical Record.

3. 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
Authentication identifies the author of an entry in the patient’s record and that entry must be verified or validated by the
author. Only the author can legally sign an entry in the health Record. Countersignatures may also be required according to
organizational policy.

4. 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.
The format/chart order of the record is strictly up to the healthcare facility, but it must include clinical and administrative data for medical
decision making.

5. 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

6. 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
There are advantages and disadvantages to the different formats/chart order of the medical record. It is part of the
Facility’s responsibility to ensure communication of care among different practitioners and other departments within the facility
and this is achieved through the information in the medical record.

7. 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
Class Question: What are some of the advantages and disadvantages of each system???

8. 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

9. 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
JCAHO provides accreditation to all types of healthcare organizations, all of whom must maintain patient
records according accreditation standards. The completion of the medical record is one of those standards. To be
compliant the record must be completed within 30 days or it is considered delinquent.

10. Health Information Department
Cancer registry
Coding and abstracting
Image processing
Incomplete record processing
Medical transcription
Record circulation
Release of information processing
The items listed here are different sub-locations/functions within a HIM department.

11. Role of the HIM Department in Record Completion
Record assembly
Quantitative analysis
Qualitative analysis
Concurrent analysis
Statistical analysis
The HIM department must perform the above functions to achieve record completion for accuracy and efficiency.

12. Reading
The reading assigned in this unit is Chapter 4 from the textbook. This chapter discusses the documents in an acute care chart and the elements needed on each document.

13. Discussion
Please respond to the discussion topic and then review and respond to two of your classmates.
Discuss the illnesses and conditions that are acute care and the documents needed in the chart that would correspond to those diagnoses.

14. HW Assignment
Complete exercises 1, 2 and 3 in the reading text for Chapter 4 15 points
Lab assignment from the lab manual 4-1   5 points
Quiz 2 is completed in this unit
The term project is to be worked on in this unit

15. Quiz
Unit 3 Quiz is on chapter 4 of your textbook

16. Questions