Patient Record, Outpatient, And Physician Office

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
It is essential that every report in the patient record contain patient identification, which consists of the patient’s name and some other piece of identifying information such as medical record number, date of birth, or social security number. Every report in the patient record and every screen in an automated record system must include the patient’s name and identification number. In addition, for reports that are printed on both sides of a piece of paper, patient identification must be included on both sides. Documents that contain multiple pages (e.g., computer-generated lab reports) must include patient identification information on all pages. NOTE: Some patients insist on the use of an alias, which is an assumed name, during their encounter. The patient might be a movie star or sports figure; receiving health care services under an alias affords privacy (e.g., protection from the press). The name that the patient provides is accepted as the official name, and the true name can be entered in the master patient index as an AKA (also known as). However, the true name is not entered in the patient record or in the billing files. Patients who choose to use an alias should be informed that their insurance company probably will not reimburse the facility for care provided, and the patient will be responsible for payment.
These codes are recorded on the face sheet and in the facility’s abstracting system. (Some facilities allow coders to enter diagnoses/ procedures from the discharge summary onto the face sheet or to code directly from the discharge summary if the face sheet does not contain diagnoses/ procedures. If, upon review of the record, coders determine that additional diagnoses/procedures should be coded, they contact the responsible physician for clarification.) NOTE: Abstracting is discussed in Chapter 7. Prior to 1995, the Health Care Financing Administration, (HCFA, now called Centers for Medicare and Medicaid Services, CMS) required physicians to sign an attestation statement, which verified diagnoses and procedures documented and coded at discharge. Medicare originally required the statement because, when the diagnosis-related groups’ prospective payment system was implemented in 1983, there was concern that physicians would document diagnoses and procedures that resulted in higher payment for a facility (called upcoding or maximizing codes, and also known as DRG creep). In 1995, the attestation requirement was dropped. At the same time, some hospitals also eliminated the requirement that physicians document diagnoses/procedures on the face sheet since this information is routinely documented as part of the