Question

Discussion Topic Select one of the following: Inpatient Records Outpatient Records Physician Office Records Based upon your own practice setting, or your desired practice setting, discuss the key components of the patient record. What makes a thorough and high-quality patient record in your setting?

>Outpatient

Each student must post (1) substantial initial post for each with a minimum of 200 words per topic by Thursday of each week before 11:59 PM.

Answer 1

Ans.

Inpatient Records--

Clinical (hospital inpatient) records are compiled when active duty members are actually hospitalized while in the service. An overnight stay or admission generally makes a patient an inpatient.

Inpatient medical records

● Hospital-specific admission;
● Initial history and physical exam;
● Progress notes and insurance;
● Consultations;
● Nursing notes;
● Labs;
● Radiology;
● Surgery reports;
● Doc's orders

Outpatient records--

Outpatient medical records

● Does not include:
admitting data;
flow sheets and graphic charts;
operating room reports;
admission history and physical exam;
medication administration sections;
miscellaneous;
doc's orders;

● Limited info due to only documenting patient encounters, not communicate with HCP

Physician office records--

Traditionally, physician's office records were for a single physician treating a group of long-term patients. The record served to remind the physician of the patient's medical history and to record the patient's treatment for billing purposes.

Key components of the patient records--

To keep things simple, a medical record contains information regarding a patient's health and medical history. The level of detail, amount of information, and type of information will vary significantly from patient to patient.
...
Patient's Medical History

• Past and present diagnosis.
• Medical care.
• Treatments.
• Allergies.

Make a thorough and high quality patient records--

An accurate written record detailing all aspects of patient monitoring is important, not only because it forms an integral part of the of the provision of care or nursing management of the patient, but because it also contributes to the circulation of information amongst the different teams involved in the patient's

Key principles

All records must be signed, timed and dated if handwritten. If digital, they must be traceable to the person who provided the care that is being documented. Ensure that you are up to date in the use of electronic systems in your place of work, including security, confidentiality and appropriate usage.

Always record your instructions in writing. Review your instructions with the patient and the patient's family. Ensure comprehension. Use a teach-back method to confirm that the patient can accurately describe his or her treatment plan.