What are some differences between the contents of patient records at an inpatient facility versus a doctor's office?

Question

What will be an ideal response?

Answer 1

Acute care hospital charts usually contain much more data about a single stay because vital signs and nursing notes are added frequently during the stay. Some items that will be found in an inpatient chart include admission and discharge summary, nursing notes, physician examination notes, orders, test results, operative reports, pathology and radiology reports, and administrative and demographic forms. Because a new chart is started for each inpatient stay, the chart will not typically contain records from previous admissions.
Doctors' offices tend to keep a single chart per patient, integrating documents from all previous visits, medical history, consults, lab results, and reports from other providers. The principal document is the physician's note, which details the observation and findings, but often includes the physician's orders and plan of treatment. In addition to demographic and social history information, many offices keep records of communications with the patient and their insurance plans in the chart as well.