Records: Medical care and Affected person Record Article



Content of the Patient Record: Inpatient, Outpatient, and Doctor Office Chapter Outline

Search terms Objectives Launch General Documents Issues Clinic Inpatient Record—Administrative Data Clinic Inpatient Record—Clinical Data Hospital Outpatient Record Physician Office Record Varieties Control and Design Net Links Brief summary Study Register Chapter Review

Key Terms

addressograph machine entry note admission/discharge record acknowledging diagnosis improve directive improve directive notification form against medical advice (AMA) alias secours report portico record additional reports additional service visit anesthesia record antepartum record anti-dumping guidelines APGAR report attestation affirmation automatic quit order autopsy autopsy survey bedside port system delivery certificate delivery history case management note 109 certificate of birth license of fatality chief grievance (CC) scientific data medical rГ©sumГ© comorbidities complications circumstances of admission consent to admission assessment consultation record death certificate

110 • Chapter a few

dietary improvement note differential box diagnosis relieve note discharge order relieve summary doctors orders DRG creep long lasting power of attorney crisis record face encounter contact form face linen facility identification family history fee slip final diagnosis girl progress note forms panel graphic linen health care proxy history good present disease (HPI) knowledgeable consent bundled progress paperwork interval history labor and delivery record licensed doctor macroscopic increasing codes medication administration record (MAR)

necropsy necropsy report neonatal record newborn recognition newborn physical examination newborn progress records non-licensed medical specialist nurses remarks nursing care plan medical discharge synopsis nursing documentation obstetrical record occasion of service practical, effectual record outpatient visit previous history pathology report patient identification sufferer property contact form patient record committee physical examination medical professional office record physician instructions postanesthesia be aware postmortem report postoperative be aware postpartum record preanesthesia evaluation note prenatal record preoperative note primary diagnosis

principal diagnosis main procedure progress notes provisional autopsy report read and verified (RAV) recovery place record rehab therapy progress note respiratory therapy progress note report on systems (ROS) routine order secondary diagnostic category secondary procedures short stay short stay record cultural history ranking order prevent order superbill telephone buy call back insurance plan tissue report transfer buy Uniform Portable Care Info Set (UACDS) Uniform Clinic Discharge Info Set (UHDDS) upcoding spoken order crafted order


At the end on this chapter, the student should be able to:

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Explain general documentation issues that impact all patient information Differentiate amongst administrative, economical, and specialized medical data gathered on patients List the contents of inpatient, outpatient, and medical doctor office data

Identify certification standards and federal and local regulations and rules that effect patient record content Details forms design and control requirements, such as role in the forms panel

Content in the Patient Record: Inpatient, Outpatient, and Medical professional Office • 111


Health care providers (e. g., private hospitals, physician office buildings, and so on) are responsible to get maintaining a list for each individual who will get health care solutions. If certified, the supplier must abide by standards that impact patient record keeping (e. g., Joint Commission on Certification of Health care Organizations). In addition , federal and local regulations and regulations (e. g., Medicare Conditions of Participation) provide assistance as to patient record articles requirements (e. g., inpatient, outpatient, and so on). To appropriately abide by...