Content of the Patient Record: Inpatient, Outpatient, and ...

Chapter 6 Content of the PatientRecord: Inpatient, Outpatient, andPhysician OfficeChapter OutlineKey Termsaddressograph machineadmission noteadmission/discharge recordadmitting diagnosisadvance directiveadvance directive notification formagainst medical advice (AMA)aliasambulance reportambulatory recordancillary reportsancillary service visitanesthesia recordantepartum recordanti-dumping legislationAPGAR scoreattestation statementautomatic stop orderautopsyautopsy reportbedside terminal systembirth certificatebirth historycase management notecertificate of birthcertificate of deathchief complaint (CC)clinical dataclinical r sum comorbiditiescomplicationsconditions of admissionconsent to admission Key Terms Objectives Introduction General Documentation Issues Hospital Inpatient Record AdministrativeData Hospital Inpatient Record Clinical Data OPPS Major and Minor Procedures Hospital Outpatient Record Physician Office Record Forms Control and Design Internet Links Summary Study Checklist Chapter Review1199781133889731, Essentials of Health Information Management: Principles and Practices, Second Edition, Green/Bowie - Cengage rights reserved.

postoperative note postpartum record preanesthesia evaluation note prenatal record preoperative note principal diagnosis principal procedure progress notes read and verified (RAV) recovery room record rehabilitation therapy progress ... information (e.g., patient name, gender, etc.), and other information (e.g., advanced directive).

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  Name, Preoperative, Postoperative

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