Patient Records Essay

Submitted By Shugg77
Words: 678
Pages: 3

WK 4 Checkpoint: Patient Report
HCR/210 Patient Records Keeping It Real

|Name of Report |Brief Description of Contents |Who Signs the Report |Filing Standard |
|Face Sheet |Patient identification, financial data, clinical |Attending physician |30 days following patient |
| |information (admitting and final diagnoses) | |discharge |
|Advanced Directives |Advance directive is the general term that refers to a |Patient's and the medical |Prior to surgery |
| |person's request (oral and/or written) concerning health |facility's representative | |
| |care, should he or she become incompetent. There are two | | |
| |main documents in an advance directive: a living will and | | |
| |a durable power of attorney for health care. | | |
|Informed Consent |Patient consent to a medical procedure or treatment after |The patient and the physician|Prior to any medical or |
| |being fully advised of relevant medical facts and the |representative |surgical procedure |
| |risks involved. | | |
|Patient Property Form |Documents items that the patient has on them at the time |The patient and medical staff|(Not stated in the text, but |
| |of admittance. |administrator |probably at the time property |
| | | |is taken from the patient) |
|Discharge Summary |Summary of patients follow up care, prescriptions and |Attending physician |Within 30 days of discharge |
| |information on how to administer them, as well as the | | |
| |diagnosis as well as the symptoms at the time of | | |
| |discharge. | | |
|History and Physical |The patient’s chief complaint, present illness history, |Staff member who directly |Variable between JCAHO and |
|Examination |past history, family history, social history, current |obtained this information |AOA, but usually not more than|
| |medications, and review of systems |from the patient |7 days before or 48 hours |
| | | |after admission |
|Consultation Reports |Date, medication, reason, consulting physician, history of|Referring physician. |When received. |
| |present illness, physical examination, lab data, and | | |
| |assessment along with physician notes. | | |
|Physician Orders |Orders given in the form of written, verbal communication,|Nurse on duty initials the |Specified by facility. |
| |and over the phone by the doctor concerning medication or |physician order form. |