Health Records

in
Ambulatory Care
Facilities
By: Seema Sondhi
11/22/2015

Ambulatory care is care provided to patients on an outpatient basis

and includes medical services such as those received at physicians offices,
dialysis clinics, public health clinics, diagnostic imaging centers, ambulatory
surgical centers, and several other types of outpatient services. Since
procedures are performed as outpatient measures, costs are significantly
reduced by not keeping patients admitted in a hospital and using the
hospitals resources. In the modern era, as patients are looking everywhere
to save time and money, ambulatory care centers seem to be getting more
and more popular. These centers are popping up everywhere, in all
neighborhoods and towns, whether they are urgent care centers, diagnostic
centers, or physician offices.
As technology continues to advance, patients today are able to check
in and register electronically at these ambulatory care centers. Doctors and
nurses are even able to communicate with their patients using
videoconferencing, emails, and remote monitoring. It is believed that in the
future, most routine patient visits will be e-visits which means that instead of
exam rooms, ambulatory care centers will need more common group spaces.
To keep up with the electronic world, patient health records must also
be evaluated very carefully to make sure they are flawless. Most medical
facilities, including ambulatory care centers, are all moving away from paper
based health records to electronic health records. This change will
eventually save time, money, and improve healthcare all across the country.

There will be a decrease in health record inconsistencies and duplicate

procedures if health record documentation is performed correctly.

There are several pertinent components of ambulatory care health

records for all patients that are required. It is imperative that all health
record documentation be done precisely and on time regardless of the
intensity of patient care. Leaving out just one miniscule detail due to
documenting in a rush can lead to a very serious tragedy. It is the contents
of these health records which aid health providers in managing and
delivering patient care, validating reimbursement claims, and protecting the
legal interests of themselves and their patients.
The very first component of an ambulatory care health record is the
registration record. The registration record documents a patients
demographic data which includes name, address, date of birth, ethnicity,
social security number, insurance company information, employer, and other
basic elements. This information may be available by individual facilities for
research, marketing, and planning. It is greatly advised that each health
record have a unique identifying number assigned to each patient included in
the registration record.
All ambulatory care health records are required to include a problem
list, or summary list. This is a list of all medical and surgical problems,
including social and psychiatric problems, which have relevantly affected the

patients long-term well-being. The problem list is provided for the

healthcare practitioner to use to evaluate patient care and assist in medical
treatment plans. A medication list is also included so the health provider is
aware of a patients acute and chronic illnesses and can adjust the drug
regimen accordingly to avoid drug interactions and

allergies. This list provides the names of medications, dosage amounts,

dispensing instructions, prescription dates, and any problem numbers for
each medicine.
A patient history questionnaire is filled out by the patient to provide
important information to the health care provider about past or present
medical conditions. An updated questionnaire should replace the previous
one approximately every five years. A detailed medical history is required in
an ambulatory care health record so that the medical provider can
understand the patients complaints, symptoms, and all past and present
medical, personal and family health history. It is recommended that each
medical history include a chief complaint, present illness, past medical
history, personal and family history. The medical history part of the health
record contains subjective information given by the patient. A physical
examination performed by the healthcare provider must include an
assessment of all body systems and immunization records. This part of the

medical record contains medical information which is evaluated by the

provider.
Progress notes are another important part of an ambulatory care
health record. These are used to summarize the patients treatment and
health status at each visit and must be legible and uniform. The SOAP
format of progress notes is a commonly used one in which each part of the
note is represented by the SOAP acronym: Subjective, Objective,
Assessment, Plan. The subjective portion of the notes are the patients
complaints and remarks. The objective part contains physical exam and lab
results. The assessment contains the patients diagnosis and the plan
includes patient education, referrals, and medical treatment. In ambulatory
care

settings, most patients have to go to other places to get some orders

completed as in prescriptions, therapies, diagnostic tests, and other services.
These orders are known as physician orders and must be included in the
ambulatory care health record. Signed consents are also a very significant
requirement of health records for ambulatory care centers.
There are some elements of ambulatory health records that are
strongly recommended, but not required. One of these components include
patient instructions which must be given to patients or their representatives
regarding their aftercare, be clear and concise, and be included in the health

record as well. All instructions should be signed off on and any verbal
instructions or questions and responses should also include verification
signatures. Missed appointment forms are also recommended in case a
patient misses a follow-up appointment. Flow sheets can also be included to
effectively show maintenance of a patients healthcare. All telephone
encounters are advised to be documented including details such as callers
name and number, date and time of call, patients name, reason of call, and
responses given.
Though there is such a wide range of required elements to be included
in ambulatory care records, it is of utmost importance that none of these be
left out or abbreviated. The proper documentation of all of these
components is important for it will be used for legal purposes,
reimbursement claims, and to improve and perfect the quality of patient
health care. All elements must be detailed, complete, and comprehensive as
they can possibly be the difference between life and death.

References
Fahrenholz, C.G & Russo, R. (c2013). Documentation for Health Records. Illinois: AHIMA Press
publications.

Healthcaredesignmagazinecom. (2015). Ambulatory Care Centers Make Their

Move. Retrieved from:
http://www.healthcaredesignmagazine.com/article/ambulatory-care-centers-make-their-move

Mcalearney, A.S., Hefner, J.L., Sieck,C., Rizer,M., & Huerta, T.R. (2015). Fundamental Issues in
Implementing an Ambulatory Care Electronic Health Record. Journal of the American Board
of Family Medicine, 28(1),55-64. Retrieved from:
http://www.medscape.com/viewarticle/837890

Practicefusioncom. (2010). Ambulatory EHR vs hospital inpatient EHR solutions. Retrieved from:
http://www.practicefusion.com/blog/emrs-hospital-vs-ambulatory-solutions/

Royse, D. (2015). Who needs beds? New ambulatory centers offer everything except inpatient
care. Retrieved from:
http://www.modernhealthcare.com/article/20150912/MAGAZINE/309129973