BOX 2-2A
PRIMARY USES OF PATIENT RECORDS
Document services received
Constitute proof of identity
Self-manage care
Verify billing
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)
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
Allocate resources
Analyze trends and develop forecasts
Assess workload
Communicate between departments
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
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