Records: Health Care and Patient Record

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CHAPTER

5

Content of the Patient Record: Inpatient, Outpatient, and Physician Office Chapter Outline
Key Terms Objectives Introduction General Documentation Issues Hospital Inpatient Record—Administrative Data Hospital Inpatient Record—Clinical Data Hospital Outpatient Record Physician Office Record Forms Control and Design Internet Links Summary Study Checklist Chapter Review

Key Terms
addressograph machine admission note admission/discharge record admitting diagnosis advance directive advance directive notification form against medical advice (AMA) alias ambulance report ambulatory record ancillary reports ancillary service visit anesthesia record antepartum record anti-dumping legislation APGAR score attestation statement automatic stop order autopsy autopsy report bedside terminal system birth certificate birth history case management note 109 certificate of birth certificate of death chief complaint (CC) clinical data clinical résumé comorbidities complications conditions of admission consent to admission consultation consultation report death certificate

110 • Chapter 5

dietary progress note differential diagnosis discharge note discharge order discharge summary doctors orders DRG creep durable power of attorney emergency record encounter encounter form face sheet facility identification family history fee slip final diagnosis follow-up progress note forms committee graphic sheet health care proxy history history of present illness (HPI) informed consent integrated progress notes interval history labor and delivery record licensed practitioner macroscopic maximizing codes medication administration record (MAR)

necropsy necropsy report neonatal record newborn identification newborn physical examination newborn progress notes non-licensed practitioner nurses notes nursing care plan nursing discharge summary nursing documentation obstetrical record occasion of service operative record outpatient visit past history pathology report patient identification patient property form patient record committee physical examination physician office record physician orders postanesthesia note postmortem report postoperative note postpartum record preanesthesia evaluation note prenatal record preoperative note primary diagnosis

principal diagnosis principal procedure progress notes provisional autopsy report read and verified (RAV) recovery room record rehabilitation therapy progress note respiratory therapy progress note review of systems (ROS) routine order secondary diagnoses secondary procedures short stay short stay record social history standing order stop order superbill telephone order call back policy tissue report transfer order Uniform Ambulatory Care Data Set (UACDS) Uniform Hospital Discharge Data Set (UHDDS) upcoding verbal order written order

Objectives
At the end of this chapter, the student should be able to:

• •

• • •

Explain general documentation issues that impact all patient records Differentiate among administrative, financial, and clinical data collected on patients List the contents of inpatient, outpatient, and physician office records

Identify accreditation standards and federal and state laws and regulations that impact patient record content Detail forms design and control requirements, including the role of the forms committee

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 111

INTRODUCTION
Health care providers (e.g., hospitals, physician offices, and so on) are responsible for maintaining a record for each patient who receives health care services. If accredited, the provider must comply with standards that impact patient record keeping (e.g., Joint Commission on Accreditation of Healthcare Organizations). In addition, federal and state laws and regulations (e.g., Medicare Conditions of Participation) provide guidance as to patient record content requirements (e.g., inpatient, outpatient, and so on). To appropriately comply with...
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