Inpatient Health Record Documentation

The inpatient health record is generated when a patient is provided with room, board, and continuous general nursing care in an area of an acute-care healthcare organization, such as a hospital, where the patient generally stays overnight at that healthcare organization. The documents typically found in an inpatient health record include but are not limited to history and physical (H&P), consultation reports, physician’s orders and progress notes, nursing assessments and progress notes, as well as a discharge summary. Over the years, there has been a dramatic shift in the delivery of healthcare treatment and services. Many services such as surgery, infusions, and other diagnostic procedures that once required a patient to stay overnight in the hospital can be performed on an outpatient basis. Only the most severely ill patients and the most invasive procedures require an overnight stay and therefore the inpatient health record is the most complex. A discussion of the three major health records categories within the inpatient care services continuum (medical and surgical, obstetric, and newborn) follows.