Dawson:
No, the encounter form is not part of the medical record. In fact, it is suggested that "billing" forms, insurance information and patient accounting data not be stored with the record--as the record is meant to communicate and store clinical information only.
You can pretty much check out any fundamentals of HIM or Medical Records text and it'll tell you as much.
While I'm sure there's some mixed concept of this on local levels, I have to agree with the texts I've read that "billing items" and the health record are different things...
This is an older link but I actually needed this information as well.
Kevin or anyone that would like to respond,
Is this what you were referring to?
Documents Not Included in the Legal Health Record
Administrative Data and Documents
Administrative data and documents should be provided the same level of confidentiality as the legal health record. However, administrative data should not be considered part of the legal health record and would not be produced in response to a subpoena for the medical record. Healthcare organizations might more appropriately consider some administrative data and documents as working documents.
Administrative data are patient-identifiable data used for administrative, regulatory, healthcare operation, and payment (financial) purposes. Examples of administrative data include:
Abbreviation and do-not-use abbreviation lists
Audit trails related to the EHR
Authorization forms for release of information
Birth and death certificate worksheets
Correspondence concerning requests for records
Databases containing patient information
Event history and audit trails
Financial and insurance forms
Incident or patient safety reports
Indices (disease, operation, death)
Institutional review board lists
Logs
Notice of privacy practices acknowledgments (unless the organization chooses to classify them as part of the health record)
Patient-identifiable claims
Patient-identifiable data reviewed for quality assurance or utilization management
Protocols and clinical pathways, practice guidelines, and other knowledge sources that do not imbed patient data
Psychotherapy notes
Registries
Staff roles and access rights
Work lists and works-in-progress
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027921.hcsp?dDocName=bok1_027921