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  • 1. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Chapter 4The Patient Record: Hospital,Physician Office, andAlternate Health Care Settings
  • 2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Definition of Purposeof the Patient Record• Ownership of the patient record• Hospital inpatient record• Hospital outpatient record• Physician office record
  • 3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Provider DocumentationResponsibilities• 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
  • 4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Signature Stamp
  • 5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Abbreviation List
  • 6. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Development of the Patient Record• Date order of patient record reports• Outpatient record: handling repeat visits• Physician office record: continuity of care
  • 7. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Patient Record Formats• Primary and secondary sources ofinformation• Source-oriented record (SOR)• Problem-oriented record (POR)• Integrated record
  • 8. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Patient Record Formats(Continued)• Automated record systems• Computers in health care• Longitudinal patient record• Advantages and disadvantages of manualand automated record systems
  • 9. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Archived Records• Record retention laws• Alternative storage methods• Facility retention policy considerations• Off-site storage
  • 10. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Patient Record CompletionResponsibility• Governing board and facility administration• Attending physicians and other health careprofessionals
  • 11. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.Role of the HIM Department inRecord Completion• Record assembly• Quantitative analysis• Qualitative analysis• Concurrent analysis• Statistical analysis