The Health Information Management Documentation

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Table of Contents

Introduction
History and Physical
Progress Note
Operative Report
Discharge Summary
Conclusion
References

Introduction

Healthcare workers have to deal with patient data daily; thus, health information management (HIM) became essential to ensure that all documents are prepared and processed correctly. Examples of documents related to HIM include transactions, payment forms, clinical notes, outpatient records, pharmacy prescriptions, medical history, and others (Nearterm, 2018). The goal of HIM is to obtain, analyze, and protect health information that is primarily stored in digital forms nowadays (Nearterm, 2018). The Health Insurance Portability and Accountability Act obliges healthcare organizations to ensure the safety of patient data (Nearterm, 2018). This paper aims to discuss four types of medical documentation regularly used in clinical practice: progress notes, history and physical, operative reports, and discharge summaries. These four documents are essential for describing and understanding a patient’s condition to make a definitive diagnosis and select a proper treatment plan.

History and Physical

Patient interviewing, physical examination, and creating medical history records are integral elements of structuring health information for monitoring and follow-up. The purpose of writing history is to have organized data about a patient’s current status and complaints, past illnesses, and social and family history (Knott, 2021). The goal of notes on physical examination is to present an objective summary of the clinician’s findings and observations (Knott, 2021). History usually includes present symptoms and the onset of the disease, past medical information, medications, immunizations, information about chronic or inherited illnesses in the family, occupation, and unhealthy habits (Knott, 2021). During the physical examination, a doctor observes and then performs auscultation and palpation, depending on the current complaint. Physicians should describe all organs and systems examined to see what deviates from the norm in that specific individual. This document is universally used in inpatient and outpatient settings but may vary between departments.

Progress Note

Progress notes serve the purpose of presenting an update on a patient’s status after the treatment was started. The purpose of a progress note is to provide a summary of an interval status of a person during a hospitalization or some other healthcare encounter (HealthIT.gov, 2022). It usually includes information about the previous observation and current status of an individual who requires medical attention. It is used both for outpatient and inpatient observations of patients.

Operative Report

Operative report is usually written in surgical departments after a specific procedure is performed. It presents the names of surgeons, nurses, and assistants, how the surgery was performed, the findings, and the outcomes (American Institute for Healthcare Management, 2019). Operative notes aim to ensure that doctors can review if the procedure was performed correctly and attained the original goal for which the surgery was performed: treatment, biopsy, or exploration.

Discharge Summary

A medical document written at the end of a person’s hospitalization is a discharge summary. Its goal is to summarize the entire time of a patient’s hospital stay from the day of admission. Discharge note includes such information as reasons for hospitalization, significant findings, treatment and procedures provided, patient’s condition at the discharge, instructions, and attending physician’s signature (Ross, 2018). It is primarily written in inpatient settings after a hospitalized individual receives therapeutic or surgical treatment.

Conclusion

Health information management’s primary function is to regulate the creation process of medical records. The types of HIM documentation vary, and some examples are discharge summary, operative report, history and physical, and progress notes. These documents serve specific purposes of organizing health information obtained from the patient during the outpatient visit or hospital stay to have an objective overview of the status and progress after the initiation of treatment.

References

American Institute for Healthcare Management. (2019). Purposes of patient records. Web.

HealthIT.gov. (2022). Documentation of clinical notes. Web.

Knott, L. (2021). History and physical examination. Patient. Web.

Nearterm. (2018). What is health information management & why is it important?Web.

Ross, S. M. (2018). What should be included in a hospital discharge summary?CureAtr. Web.

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