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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