A patient is any recipient of health care services performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, healthcare specialist or other healthcare provider.
Patient can be categorized into outpatient and inpatient based on the duration of stay in the hospital/clinic:
- Patient journey is a series of events a patient experiences when engaging with medical service. It includes a variety of encounters, starting from trigger event to visiting healthcare provider to follow-up care instructions.
- Patient journey can be categorized into three major categories : pre-visit, visit, and post-visit.
- Patient encounter is the interaction between patient and provider where healthcare services are provided and documented.
- Patient encounter can be categorized on the basis of the space it takes place in. Patient encounter can be ambulatory, emergency, home health, inpatient and virtual.
- When a patient visits a healthcare provider, the provider fills encounter form/superbill at the end of each visit. It details the type of medical services provided to the patient, when it was provided and what category the medical services fall under for coding purpose.
- Encounter forms capture three sets of data: patient profile ( patient demographic, billing information, insurance information), clinical observations( physical assessment, medical history, diagnosis) and treatment (services provided during the visit)
- The encounter forms can be in digital form. e-encounter forms allows providers to store all the patient health information like medical history, diagnosis, treatments, lab tests in digital version which is also known as Electronic Health Record (EHR). EHR can also be shared between different providers.
- In a patient encounter form, the details on the diagnosis and treatment provided are documented. This serves as a basis for medical coders to assign respective medical codes to the healthcare services rendered and to submit medical claims.
- Patient encounter data serves as a basis for billing and receipt of payment for medical services.