Health care facilities treat many types of patients. For hospitals, patients are called inpatients and stay overnight. For outpatient facilities, such as a clinic or ambulatory center, patients will arrive for an appointment, treatment, test, or procedure and then return home the same day. For a long-term facility, such as a nursing home, patients will stay for weeks or months—even years. Keeping a patient record of treatment rendered is most important to maintain a health care facility and support the reimbursement process to receive payment for services rendered. The patient record is a legal document. There is a saying in health care, “If it was not documented, it was not done.” This patient data can be in paper or electronic format.
To understand the similarities and differences of the types of patient data collected by these different facilities, and to understand the types of documents that contain this data for paper health record or electronic health record systems, complete the following assignment:
- Describe 5 documents in the patient medical record and the purpose for each.
- State whether these documents would be used in hospital, outpatient, or long-term facilities.