This document discusses patient records in hospital, physician office, and alternate healthcare settings. It covers the ownership and purpose of patient records, provider responsibilities for documentation including signatures and abbreviations, development of records over time and repeat visits, common record formats like problem-oriented records, the use of manual and automated systems, record retention policies, and the roles of staff and departments in completing records.

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Chapter 4
The Patient Record: Hospital,
Physician Office, and
Alternate Health Care Settings

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Definition of Purpose
of the Patient Record
• Ownership of the patient record
• Hospital inpatient record
• Hospital outpatient record
• Physician office record

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Provider Documentation
Responsibilities
• 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

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Signature Stamp

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Abbreviation List

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Development of the Patient Record
• Date order of patient record reports
• Outpatient record: handling repeat visits
• Physician office record: continuity of care

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Patient Record Formats
• Primary and secondary sources of
information
• Source-oriented record (SOR)
• Problem-oriented record (POR)
• Integrated record

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Patient Record Formats
(Continued)
• Automated record systems
• Computers in health care
• Longitudinal patient record
• Advantages and disadvantages of manual
and automated record systems

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Archived Records
• Record retention laws
• Alternative storage methods
• Facility retention policy considerations
• Off-site storage

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Patient Record Completion
Responsibility
• Governing board and facility administration
• Attending physicians and other health care
professionals

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Role of the HIM Department in
Record Completion
• Record assembly
• Quantitative analysis
• Qualitative analysis
• Concurrent analysis
• Statistical analysis