Health Record Content, Documentation Standards and Record Completion · 6 min read
Purposes, Users and Formats of the Health Record
The chapters in this section move from the big picture (why records exist and how they are organized) to the details the exam loves to test: the required reports in an acute care record and their deadlines, record content in other care settings, the Medicare Conditions of Participation and Joint Commission standards, authentication and amendment rules, quantitative and qualitative analysis, deficiency tracking and delinquency rates, forms control, and the difference between the legal health record and the designated record set.
This chapter explains why health records exist, who uses them, and the main ways records are organized and stored. These ideas are the foundation for almost every other topic in Domain 1.
What a Health Record Is
A health record is the collection of information about a patient's health and the care given to that patient by a provider or organization. It documents who the patient is, what was wrong, what was done, who did it, when it was done, and what happened as a result. In a hospital the record for one stay is often called an encounter record or episode of care, and all of a patient's encounters together make up the patient's longitudinal record.
The health record serves as a communication tool among caregivers, a legal document, the source for billing and coding, and a source of data for research, quality and public health. Because it serves so many purposes, accuracy and completeness matter to everyone in the organization, not just to HIM.
Primary vs Secondary Uses
A primary use is a use directly related to the care of the individual patient. A secondary use is any use that is not direct patient care, even if it is important to the organization or to society.
| Type of Use | Examples | Typical Users |
|---|---|---|
| Primary | Planning and delivering care, communicating among caregivers, patient self-management | Physicians, nurses, therapists, the patient |
| Primary | Reimbursement for the care given to that patient | Coders, billers, payers |
| Secondary | Quality improvement, accreditation surveys, peer review | Quality staff, surveyors, medical staff committees |
| Secondary | Research, registries, public health reporting | Researchers, cancer registrars, health departments |
| Secondary | Education, legal proceedings, policy making | Students, attorneys, courts, government agencies |
Users are also grouped as individual users (people who look at the record itself, such as a nurse or a coder) and institutional users (organizations that use record data, such as a payer, an accrediting body or a state health department).
Record Formats: How Content Is Organized
There are three classic ways to arrange the documents within a record. Each still appears on the exam, even though an electronic health record (EHR) lets users view data in many arrangements.
| Format | How It Is Arranged | Strength | Weakness |
|---|---|---|---|
| Source-oriented | Sections by department or source (physician orders, lab, radiology, nursing) | Easy to file and to find one department's documents | Hard to follow one problem across disciplines |
| Problem-oriented | Organized around a numbered problem list | Shows the reasoning for each problem; strong continuity | Takes discipline to keep the problem list current |
| Integrated | Strict date order, with documents from all sources mixed together | Shows the full sequence of care | Hard to compare data of one type (all lab results) |
The problem-oriented medical record (POMR), developed by Dr. Lawrence Weed, has four parts: a database (history, physical exam, initial results), a problem list (each problem numbered and titled), an initial plan for each problem, and progress notes written against each numbered problem. Progress notes in a POMR use the SOAP format.
| Letter | Stands For | Example Content |
|---|---|---|
| S | Subjective | What the patient reports: "My chest still feels tight." |
| O | Objective | What the clinician measures or observes: BP 142/88, lungs clear |
| A | Assessment | The clinician's conclusion: chest pain, likely musculoskeletal |
| P | Plan | Next steps: continue NSAID, recheck in two weeks |
Record Media: Paper, Hybrid and Electronic
A paper record is created and stored on paper. A hybrid record is part paper and part electronic, for example an EHR for physician notes and orders while some consent forms and outside records are on paper or scanned. A fully electronic record is created, stored and accessed in electronic systems, with outside paper documents scanned and indexed into the EHR.
Most hospitals operate some form of hybrid record during transitions. Hybrid records create risks: users may not know where to find a document, the legal health record may be split across systems, and release-of-information (ROI) staff may miss part of the record. For this reason the HIM department keeps a matrix (sometimes called a legal health record map or source system matrix) that lists each document type, its media (paper or electronic), the system where it lives, and whether it is part of the legal health record.
HIM Scenario: Brookline Regional Hospital still stores paper fetal monitor strips while all other labor and delivery documentation is in the EHR. An attorney requests the complete record of a delivery. The ROI specialist checks the hospital's legal health record matrix, sees that fetal strips are kept on paper in the HIM storage area, and pulls them along with the electronic record. Without the matrix, the release would have been incomplete.
Key Takeaways
- Primary uses support care of the individual patient, including payment for that care; secondary uses are everything else, such as research, registries and quality reporting.
- Source-oriented records group by department, problem-oriented records group by numbered problem, and integrated records are in strict date order.
- SOAP notes run Subjective, Objective, Assessment, Plan; a vital sign is Objective and a diagnosis is Assessment.
- Hybrid records require a document map showing where each part of the record lives and which parts are in the legal health record.
- Exam questions reward knowing who uses the record and why, not memorizing textbook history.
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