HI 205 Chapter4.4ed

1. Chapter 4
Introduction to
the Patient
Record

2. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 2
Purpose of the Patient Record
• Ownership of the patient record
• Hospital inpatient record
• Hospital outpatient record
• Physician office record
• Alternate care settings

3. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 3
Provider Documentation
Responsibilities
• Authentication of patient record entries
– Signatures
– Countersignatures
– Initials
– Fax signatures
– Electronic signatures
– Rubber stamp signatures
– Abbreviations used in the patient record
– Legibility of patient record entries
– Timeliness of patient record entries
– Amending the patient record

4. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 4
Abbreviation List

5. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 5
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. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 6
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)
• History physical impression plan (HPIP)

7. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 7
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

8. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 8
Patient Record Completion
Responsibility
• Governing board and facility administration
• Attending physicians and other health care
professionals

9. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 9
Role of the HIM Department in
Record Completion
• Record assembly
• Quantitative analysis
• Qualitative analysis
• Concurrent analysis
• Statistical analysis