The document discusses the contents and components of inpatient, outpatient, and physician office medical records. It describes the types of forms and documentation included such as face sheets, consent forms, clinical reports, progress notes, and ancillary reports. It also discusses general documentation issues like patient identification and date/time stamps. Additionally, it addresses the role of forms committees in facilitating efficient use of records and ensuring documentation quality and compliance.

1. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Chapter 6
Content of the Patient Record:
Inpatient, Outpatient, and
Physician Office Records

2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
General Documentation Issues
• Patient identification
• Facility identification
• Addressograph
• Dating and timing patient record entries

3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Face Sheet
• Identification/demographic data
• Financial data
• Clinical data

4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Additional Patient Record Forms
• Advance directives
• Informed consents
• Patient property form
• Certificate of death

5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
DNR Advance Directive
Consent Form

6. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Hospital Inpatient Records:
Clinical Data
• Emergency record
• Discharge summary/clinical résumé
• History and physical examination
• Consultation report
• Physician orders
• Progress notes
• Anesthesia record

7. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Hospital Inpatient Records:
Clinical Data (Continued)
• Operative record
• Pathology report
• Recovery room record
• Ancillary reports
• Nursing documentation
• Special reports
• Autopsy reports

8. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Hospital Outpatient Record
• Short stay record
• Uniform Ambulatory Care Data Set
(UACDS)
• Outpatient visit
• Encounter
• Ancillary service unit/occasion of service

9. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Physician Office Record
• Patient registration form
• Problem list
• Medication list
• Progress notes
• Ancillary reports
• Encounter form, superbill, or fee slip

10. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Forms Control and Design
• Forms committee or patient record committee
• Role of committee
– Facilitate efficient use of patient record
– Streamline the forms approval process
– Ensure documentation is compliant
– Enhance quality of documentation