Health records Documentation by Settings

Despite different settings in which healthcare can be provided—hospitals, ambulatory surgery centers, physician offices, long-term care facilities—health records contain two distinct types of information: clinical and administrative (defined later in the chapter). A healthcare organization must maintain a health record on every patient whom they treat. Hospitals frequently use a centralized health record. Having all patient care records stored together enables physicians and other healthcare providers to see the documentation of all the care provided to the patient by others. In a centralized health record, the inpatient and outpatient health record documentation is maintained in one health record rather than in separate health records. Whether the health record is paper-based, electronic, or hybrid, there are distinct differences in the documentation found in the health record. Inpatient, emergency department, ambulatory, ambulatory surgery, ancillary, physician office, long-term care, rehabilitation, and ­behavioral health settings are discussed in more detail in the section that follows.