hcr210r3_appendix_c_patient_reports[1] - current...

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Axia College Material Appendix C Acute Care Patient Reports Fill in the following table with a general description of each type of patient report, who may have to sign or authenticate it, and the standard time frame that JCAHO or AOA requires for it to be completed or placed in the patient’s record. Four of the reports have been done for you. Name of Report Brief Description of Contents Who Signs the Report Filing Standard Face Sheet Patient identification, financial data, clinical information (admitting and final diagnoses) Attending physician 30 days following patient discharge Advanced Directives Informed Consent Patient Property Form (Not stated in the text, but probably at the time property is taken from the patient) Discharge Summary History and Physical Examination The patient’s chief complaint, present illness history, past history, family history, social history,
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Unformatted text preview: current medications, and review of systems Staff member who directly obtained this information from the patient Variable between JCAHO and AOA, but usually not more than 7 days before or 48 hours after admission Consultation Reports Physician Orders HCR 210 Progress Notes Notes about ongoing care: changes in the patient, complications, consultations, and treatment Staff who see the patient sign and attending physician countersigns At the time they occur Anesthesia Record Operative Report A.History, physical exam, lab and X-ray exams, and preoperative diagnosis B.Therapeutic procedures C.Postoperative evaluation Surgeon or attending physician A. Prior to surgery B. Immediately after surgery C. 24 hours after surgery Pathology Report Recovery Room Record Ancillary Testing Reports HCR 210...
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This note was uploaded on 09/20/2011 for the course MGT 210 taught by Professor Ach during the Spring '11 term at University of Louisville.

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hcr210r3_appendix_c_patient_reports[1] - current...

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