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Chapter 6
Content of the Patient Record:
Inpatient, Outpatient, and
Physician Office Records

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General Documentation Issues
• Patient identification
• Facility identification
• Addressograph
• Dating and timing patient record entries

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Face Sheet
• Identification/demographic data
• Financial data
• Clinical data

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Additional Patient Record Forms
• Advance directives
• Informed consents
• Patient property form
• Certificate of death

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DNR Advance Directive
Consent Form

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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

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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