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

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

3. Face Sheet Identification/demographic data Financial data
Clinical data

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

5. DNR Advance Directive Consent Form

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

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

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

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

10. 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