Section 1: Introduction to Health Records, Content, and
Documentation
Read pages 55–69 in Chapter 2 of Health Information Management: Concepts,
Principles, and Practice. Key words:
Do-Not-Resuscitate (DNR) Order:
A DNR order is a type of advance directive that states a patient’s wish to decline
cardiopulmonary resuscitation (CPR) or other life-saving measures if their heart or
breathing stops. It is typically documented in the patient’s medical record and must be signed by
a physician to be legally valid.
Advanced Directives:
Advance directives are legal documents that outline a patient’s medical treatment preferences if
they become unable to communicate their wishes. There are three main types:
1. Durable Power of Attorney for Healthcare Decisions (DPOA-HC): A legally competent adult
designates another person (healthcare proxy) to make medical decisions on their behalf when
they are unable to do so. The term "durable" means the document remains in effect if the
person loses decision-making capacity.
2. Living Will: A document in which a competent adult states their preferences regarding life-
sustaining treatments (e.g., ventilator support, artificial nutrition, and hydration) in cases of
terminal illness or permanent unconsciousness.
3. Do-Not-Resuscitate (DNR) Order: A directive that specifically declines CPR and resuscitation
efforts in the event of cardiac or respiratory arrest.
Incident Report:
An incident report is a formal, confidential document used in healthcare to record unexpected
events, errors, or accidents that affect patients, staff, or visitors. These reports include details
such as date, time, location, involved individuals, a factual description of the event,
immediate actions taken, and recommendations for prevention.Incident reports are not part
of the patient’s medical record but are used for quality improvement and risk management.
Informed Consent:
Informed consent is a legal and ethical process where a patient receives comprehensive
information about a medical procedure, treatment, or intervention before agreeing to it. It
includes:
• Nature of the treatment
• Potential benefits and risks
, • Alternative options, including no treatment
• Possible consequences of refusal
The patient must have the capacity to understand and voluntarily consent without coercion.
Informed consent is typically documented in writing and signed by the patient and provider.
Metadata:
Metadata refers to data about data—it provides context, structure, and history for electronic
health records (EHRs) and other digital healthcare information. In healthcare, metadata includes
details such as:
• Date and time of data entry or modification
• Who accessed or changed the record
• Location of data storage
• Audit trails for security and compliance
Metadata plays a critical role in dat a security, integrity, and HIPAA compliance, ensuring
that health records are accurately maintained and tracked.
Read pages 98-141 in Chapter 4 of Health Information Management: Concepts,
Principles, and Practice. Key words:
Consultation:
A consultation is an evaluation and opinion provided by a specialist or another healthcare
provider at the request of the primary physician. The consulting provider reviews the patient’s
medical history, examines the patient, and provides recommendations for diagnosis or treatment.
Discharge Summary:
A discharge summary is a medical report prepared by a healthcare provider upon a patient’s
discharge from a healthcare facility. It includes details such as the patient’s hospital course, final
diagnosis, treatments received, condition at discharge, instructions for follow-up care, and any
prescribed medications.
Durable Power of Attorney (DPOA):
A legal document that designates a specific person (proxy) to make healthcare decisions on
behalf of an individual if they become incapacitated. It remains in effect even if the individual
loses decision-making capacity.
, History and Physical (H&P):
A comprehensive document that includes a patient's medical history and a physical examination.
It consists of:
• History of Present Illness (HPI): A detailed account of the patient’s current condition.
• Review of Systems (ROS): A systematic assessment of the patient's body systems to identify any
additional symptoms or concerns.
Hybrid Record:
A medical record system that includes both paper-based and electronic records. Many healthcare
organizations transition from paper to electronic health records (EHRs) using a hybrid system
before fully digitizing their records.
Joint Commission:
An independent, non-profit organization that accredits and certifies healthcare organizations in
the U.S. It establishes and enforces quality and safety standards for hospitals, outpatient clinics,
and other healthcare facilities.
Master Patient Index (MPI):
A database that contains key identifying information for every patient treated at a healthcare
facility. The MPI ensures that each patient has a unique record, preventing duplication and errors
in medical documentation.
Medication Administration Record (MAR):
A document that tracks the administration of medications to patients, including drug name,
dosage, route, time, and the healthcare provider responsible for administration.
Patient/Member Web Portal:
An online platform that allows patients to access their health records, schedule appointments,
communicate with providers, view test results, and manage prescriptions securely.
Personal Health Record (PHR):
A record maintained by the patient that includes their health information, medical history, test
results, medications, and treatment plans. Unlike an electronic health record (EHR), a PHR is
controlled by the patient rather than a healthcare provider.
Documentation
Read pages 55–69 in Chapter 2 of Health Information Management: Concepts,
Principles, and Practice. Key words:
Do-Not-Resuscitate (DNR) Order:
A DNR order is a type of advance directive that states a patient’s wish to decline
cardiopulmonary resuscitation (CPR) or other life-saving measures if their heart or
breathing stops. It is typically documented in the patient’s medical record and must be signed by
a physician to be legally valid.
Advanced Directives:
Advance directives are legal documents that outline a patient’s medical treatment preferences if
they become unable to communicate their wishes. There are three main types:
1. Durable Power of Attorney for Healthcare Decisions (DPOA-HC): A legally competent adult
designates another person (healthcare proxy) to make medical decisions on their behalf when
they are unable to do so. The term "durable" means the document remains in effect if the
person loses decision-making capacity.
2. Living Will: A document in which a competent adult states their preferences regarding life-
sustaining treatments (e.g., ventilator support, artificial nutrition, and hydration) in cases of
terminal illness or permanent unconsciousness.
3. Do-Not-Resuscitate (DNR) Order: A directive that specifically declines CPR and resuscitation
efforts in the event of cardiac or respiratory arrest.
Incident Report:
An incident report is a formal, confidential document used in healthcare to record unexpected
events, errors, or accidents that affect patients, staff, or visitors. These reports include details
such as date, time, location, involved individuals, a factual description of the event,
immediate actions taken, and recommendations for prevention.Incident reports are not part
of the patient’s medical record but are used for quality improvement and risk management.
Informed Consent:
Informed consent is a legal and ethical process where a patient receives comprehensive
information about a medical procedure, treatment, or intervention before agreeing to it. It
includes:
• Nature of the treatment
• Potential benefits and risks
, • Alternative options, including no treatment
• Possible consequences of refusal
The patient must have the capacity to understand and voluntarily consent without coercion.
Informed consent is typically documented in writing and signed by the patient and provider.
Metadata:
Metadata refers to data about data—it provides context, structure, and history for electronic
health records (EHRs) and other digital healthcare information. In healthcare, metadata includes
details such as:
• Date and time of data entry or modification
• Who accessed or changed the record
• Location of data storage
• Audit trails for security and compliance
Metadata plays a critical role in dat a security, integrity, and HIPAA compliance, ensuring
that health records are accurately maintained and tracked.
Read pages 98-141 in Chapter 4 of Health Information Management: Concepts,
Principles, and Practice. Key words:
Consultation:
A consultation is an evaluation and opinion provided by a specialist or another healthcare
provider at the request of the primary physician. The consulting provider reviews the patient’s
medical history, examines the patient, and provides recommendations for diagnosis or treatment.
Discharge Summary:
A discharge summary is a medical report prepared by a healthcare provider upon a patient’s
discharge from a healthcare facility. It includes details such as the patient’s hospital course, final
diagnosis, treatments received, condition at discharge, instructions for follow-up care, and any
prescribed medications.
Durable Power of Attorney (DPOA):
A legal document that designates a specific person (proxy) to make healthcare decisions on
behalf of an individual if they become incapacitated. It remains in effect even if the individual
loses decision-making capacity.
, History and Physical (H&P):
A comprehensive document that includes a patient's medical history and a physical examination.
It consists of:
• History of Present Illness (HPI): A detailed account of the patient’s current condition.
• Review of Systems (ROS): A systematic assessment of the patient's body systems to identify any
additional symptoms or concerns.
Hybrid Record:
A medical record system that includes both paper-based and electronic records. Many healthcare
organizations transition from paper to electronic health records (EHRs) using a hybrid system
before fully digitizing their records.
Joint Commission:
An independent, non-profit organization that accredits and certifies healthcare organizations in
the U.S. It establishes and enforces quality and safety standards for hospitals, outpatient clinics,
and other healthcare facilities.
Master Patient Index (MPI):
A database that contains key identifying information for every patient treated at a healthcare
facility. The MPI ensures that each patient has a unique record, preventing duplication and errors
in medical documentation.
Medication Administration Record (MAR):
A document that tracks the administration of medications to patients, including drug name,
dosage, route, time, and the healthcare provider responsible for administration.
Patient/Member Web Portal:
An online platform that allows patients to access their health records, schedule appointments,
communicate with providers, view test results, and manage prescriptions securely.
Personal Health Record (PHR):
A record maintained by the patient that includes their health information, medical history, test
results, medications, and treatment plans. Unlike an electronic health record (EHR), a PHR is
controlled by the patient rather than a healthcare provider.
