BOX 2-2A
PRIMARY USES OF PATIENT RECORDS

Patient Care Delivery (Patient)

Document services received

Constitute proof of identity

Self-manage care

Verify billing

Patient Care Delivery (Provider)

Foster continuity of care (i.e., serve as a communication tool)

Describe diseases and causes (i.e., support diagnostic work)

Support decision making about diagnosis and treatment of patients

Assess and manage risk for individual patients

Facilitate care in accordance with clinical practice guidelines

Document patient risk factors

Assess and document patient expectations and patient satisfaction

Generate care plans

Determine preventive advice or health maintenance information

Remind clinicians (e.g., screens, age-related reminders)

Support nursing care

Document services provided (e.g., drugs, therapies)

Patient Care Management

Document case mix in institutions and practices

Analyze severity of illness

Formulate practice guidelines

Manage risk

Characterize the use of services

Provide the basis for utilization review

Perform quality assurance

Patient Care Support

Allocate resources

Analyze trends and develop forecasts

Assess workload

Communicate between departments

Billing and Reimbursement

Document services for payments

Bill for services

Submit insurance claims

Adjudicate insurance claims

Determine disabilities (e.g., workmen's compensation)

Manage costs

Report costs

Perform actuarial analysis

the environment in which patient care is provided. Education, research and development, regulation, and policymaking are all considered secondary uses of the patient record.

Practical considerations forced the committee to focus on certain high-priority record uses rather than on all possible functions of the record. The four major categories of patient record uses considered by the committee were direct patient care, administration and management, reimbursement, and research.



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