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Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Chapter 6
Content of the Patient Record:
Inpatient, Outpat...
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
General Documentation Issues
• Patient identification
• Fa...
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Face Sheet
• Identification/demographic data
• Financial d...
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Additional Patient Record Forms
• Advance directives
• Inf...
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
DNR Advance Directive
Consent Form
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Hospital Inpatient Records:
Clinical Data
• Emergency reco...
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Hospital Inpatient Records:
Clinical Data (Continued)
• Op...
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Hospital Outpatient Record
• Short stay record
• Uniform A...
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Physician Office Record
• Patient registration form
• Prob...
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Forms Control and Design
• Forms committee or patient reco...
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Nur 3062 chapter 6

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Nur 3062 chapter 6

  1. 1. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 6 Content of the Patient Record: Inpatient, Outpatient, and Physician Office Records
  2. 2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. General Documentation Issues • Patient identification • Facility identification • Addressograph • Dating and timing patient record entries
  3. 3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Face Sheet • Identification/demographic data • Financial data • Clinical data
  4. 4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Additional Patient Record Forms • Advance directives • Informed consents • Patient property form • Certificate of death
  5. 5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. DNR Advance Directive Consent Form
  6. 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. 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. 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. 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. 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

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