1. Chapter 4
Introduction to the Patient
Record

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. 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

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. 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

4. © 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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. May not be scanned, copied or duplicated, or posted to a
publicly accessible website, in whole or in part
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

6. © 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)

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. 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

8. © 2016 Cengage Learning®
. May not be scanned, copied or duplicated, or posted to a
publicly accessible website, in whole or in part
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

9. © 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

10. © 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