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Document Type

Updated

The Document Type is used to help classify the medical record page, and in essence, the type of encounter. This is a crucial first step in the workflow of processing an RP# as it aids in the organization of patients’ data, that is presented to the end-user or client.

 

There is a total of twelve (12) different document types:

  • Ambulatory/Outpatient
  • EKG
  • Emergency
  • Handwritten
  • Imagery
  • Home Health
  • Inpatient
  • Diagnostic testing
  • Operation/Procedure
  • Other
  • Questionnaire
  • Virtual
Document Type
EKG – an electrocardiogram (ECG) reading. This is a graphical record of heart muscle activity recorded by an electrocardiograph.
Handwritten– any handwritten Medical Record
Imagery- Any medical record that is only an image or graphthat does not have Date Elements to Capture
Other – any non-medical records such as: Billing Record, Invoice, Request Correspondence, etc.
Questionnaire – are forms issued by our clients or ReleasePoint for the provider/doctor to fill out, is typically standalone and not included in the patient’s visit.
Ambulatory/Outpatient – any records for an outpatient visit.
  • Outpatient Medical Records
  • Progress Note, Visit Note
  • SOAP Notes (Subjective, Objective, Assessment, Plan) 
  • Lab Records
  • Therapy Notes, including Physical, Occupational, and Speech Therapy Records 
  • Urgent Care Visit
Emergency – any records for care provided during the patient’s emergency room visit
  • Often identifiable by the words ER (Emergency Room) or ED (Emergency Department)
  • Admission and Discharge Date
  • Admission and Discharge Notes
Home Health – Health care services a patient receives in a home setting. Including Assisted Living Facilities, Skilled Nursing Facilities, and Long-Term Care Facilities
  • Care Plan, OASIS or MDS
  • Admission/Discharge Assessment for Home Care/Home Health
  • Care Giver Logs/ Flowsheets 
Inpatient – any records for an inpatient visit, that may require an overnight stay, but is not an emergency visit.
  • Hospital stay Progress Note
  • Preoperative / Postoperative
  • On-Service Notes
  • Operative Notes
  • Procedure Notes
  • Admission and Discharge Date Notes
  • Overnight stay in a Medical Facility
Virtual – any records from a visit conducted over the telephone, internet, and/or video between a provider-patient; sometimes referred to as a Telehealth visit.
Diagnostic Test- A diagnostic test is a test used to help figure out what disease or condition a person has based on their signs and symptoms
Operation/Procedure- Is a surgery performed on a patient for the repair of damage or the restoration of health and especially one that involves incision, excision, or suturing

 

Tips:

  1. The facility name can often help provide context to identify the right Document Type
  2. Use Ambulatory/Outpatient if in doubt and when the context does not suggest the type of encounter
  3. Use the previous page’s Document Type if in doubt and the page header are present.