The Patient Health Record

8/8/2019 The Patient Health Record

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The patient The patient

health record health record



Patient health record is chronological,Patient health record is chronological,

documented evidence of a patient¶sdocumented evidence of a patient¶s

medical treatment.medical treatment.It is used by the healthcare providers toIt is used by the healthcare providers to

identify, evaluate, communicate, plan,identify, evaluate, communicate, plan,

treat, and document the best course of treat, and document the best course of

action for a patient.action for a patient.



Health record is aHealth record is a proof of work doneproof of work done in thein the

hospital to meet federal, state, and other hospital to meet federal, state, and other

standards & regulations.standards & regulations.

Used by insurance companies and theUsed by insurance companies and thegovernment to reimburse patients andgovernment to reimburse patients and

healthcare providers.healthcare providers.

Maintained for the legal protection of patient,Maintained for the legal protection of patient,

staff, physician and facility.staff, physician and facility.For research and health statistics.For research and health statistics.



Healthcare providersHealthcare providers ownsowns the physicalthe physicalrecord.record.

Most facilities allow the patients to reviewMost facilities allow the patients to reviewtheir own records.their own records.

Information will be releasedInformation will be released on writtenon writtenrequest with signature by the patient.request with signature by the patient.

In some instances, mental health recordsIn some instances, mental health recordsrequire a court order or subpoena torequire a court order or subpoena torelease.release.



With advances in technology, the wordsWith advances in technology, the words

that were formerly used for some alliedthat were formerly used for some allied

health concepts have changed.health concepts have changed.³Medical record´ was the terminology used³Medical record´ was the terminology used

for over 50 years, but the termfor over 50 years, but the term

health recordhealth record is used today to denoteis used today to denote

illness and wellness.illness and wellness.



The MRD has becomeThe MRD has become HIM departmentHIM department

and health records are maintained in HIMand health records are maintained in HIM

department.department.

The medical record director becomeThe medical record director become

Health information manager.Health information manager.



In the past HIM dept. were headed by anIn the past HIM dept. were headed by an

RRA or ART and assisted by medicalRRA or ART and assisted by medical

record clerks, coders and technicians.record clerks, coders and technicians.However these positions were occupied byHowever these positions were occupied by

individuals with advanced qualifications inindividuals with advanced qualifications in

business or public administration.business or public administration.



In hospitals health record has its origin inIn hospitals health record has its origin in

the admission department, outpatientthe admission department, outpatient

registration or the emergency department.registration or the emergency department.

Patients are either inpatients or Patients are either inpatients or

outpatients and health record is generatedoutpatients and health record is generated

in either case.in either case.



The admitting dept. registers patients onThe admitting dept. registers patients on

producing physicians written order for their producing physicians written order for their

admission to the hospital.admission to the hospital.

Emergency departments receives patientsEmergency departments receives patients

with acute conditions.with acute conditions.

Outpatient registration receives clinicalOutpatient registration receives clinical

patients.patients.



Major role of all these departments is to collectMajor role of all these departments is to collect

patient identification, demographic and other patient identification, demographic and other

information: name, address, sex DOB,information: name, address, sex DOB,

occupation Marital status, admitting diagnosisoccupation Marital status, admitting diagnosisetcetc

Financial entries include patient¶s employer, jobFinancial entries include patient¶s employer, job

title, address of company, insurance company,title, address of company, insurance company,

insurance identification number and type of insurance identification number and type of

payment plan.payment plan.



These departments also have the responsibilityThese departments also have the responsibility

for obtaining a patient signed conditions for for obtaining a patient signed conditions for

admission statement .admission statement .

This includes consent for treatment, outlines of This includes consent for treatment, outlines of patient responsibilities and the assurance thatpatient responsibilities and the assurance that

patient¶s confidentiality will be protected.patient¶s confidentiality will be protected.

Additional informed consents for surgery, Additional informed consents for surgery,procedures etc are obtained as appropriate.procedures etc are obtained as appropriate.



The correct spelling of patient¶s legalThe correct spelling of patient¶s legalname and birth date are importantname and birth date are importantelements to determine patientelements to determine patient

identification.identification.This is used to assign a health recordThis is used to assign a health recordnumber, maintained in the facility for number, maintained in the facility for

patient¶s life time.patient¶s life time.This information is recorded on anThis information is recorded on anadmission sheet as required federal law.admission sheet as required federal law.



Patients are admitted and treated only onPatients are admitted and treated only onthe order of an attending physician. It isthe order of an attending physician. It isthe physician¶s responsibility to order for the physician¶s responsibility to order for

diagnostic tests medications anddiagnostic tests medications andappropriate therapy.appropriate therapy.

Healthcare workers generate requisitionsHealthcare workers generate requisitions

and send to appropriate dept.and send to appropriate dept.Personnel from these dept. perform thePersonnel from these dept. perform thetests and document their results.tests and document their results.



Orders for medication and treatment areOrders for medication and treatment are

generally hand written on the chart or generally hand written on the chart or

entered into computer by the nurse or entered into computer by the nurse or

physician.physician.

Either before or after admission, theEither before or after admission, the

physician writes or dictates an admittingphysician writes or dictates an admitting

history and physical examination.history and physical examination.



This includes patient¶s chief compliant, theThis includes patient¶s chief compliant, the

history of present illness, patient¶s pasthistory of present illness, patient¶s past

medical & surgical history, family history,medical & surgical history, family history,

social history, findings on physicalsocial history, findings on physical

examination, an admission diagnosis andexamination, an admission diagnosis and

a plan for treatmenta plan for treatment

This must be placed in patient healthThis must be placed in patient healthrecord as soon as possible.record as soon as possible.



The nurse reviews attending physician¶sThe nurse reviews attending physician¶sorders, evaluates the patient andorders, evaluates the patient andestablishes a patient care plan based onestablishes a patient care plan based on

doctor¶s orders.doctor¶s orders. Also sets up forms for documentation of Also sets up forms for documentation of graphic information such as vital signs,graphic information such as vital signs,

diet, hygiene records, medication recordsdiet, hygiene records, medication recordsetc become permanent part of healthetc become permanent part of healthrecords.records.



If a diagnostic or surgical procedure isIf a diagnostic or surgical procedure is

performed, the physician performed theperformed, the physician performed the

procedure dictates the procedure.procedure dictates the procedure.

The anesthesiologist completes aThe anesthesiologist completes a

preanesthesia & postanaesthesiapreanesthesia & postanaesthesia

evaluationevaluation

When patient is hospitalized more entriesWhen patient is hospitalized more entries

are made into the health record.are made into the health record.



When patient discharged, the physicianWhen patient discharged, the physician

dictates a comprehensive discharge reportdictates a comprehensive discharge report

which includes brief history, the results of which includes brief history, the results of

laboratory tests and other tests performed,laboratory tests and other tests performed,

any complications or operativeany complications or operative

procedures, diagnoses and conclusions,procedures, diagnoses and conclusions,

discharge medications and dischargedischarge medications and dischargeinstructions to the patients.instructions to the patients.



The health records are maintained in theThe health records are maintained in the

facility for future reference.facility for future reference.



THANKYOU THANKYOU

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The Patient Health Record

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