| Item |
Method/Rationale |
Personal/ Biographical Data:
Name (O, N)
Address (N)
Home Telephone Number (N)
Date of Birth or Age (O, N)
Gender (O)
Next of Kin/ Emergency Contact with Telephone Number (O)
Employer (N)
Work Telephone Number (N)
Marital Status (N)
|
Clearly identify the patient
|
| Patient Name or ID Number on Each Page (N) |
Clearly identify the patient receiving the documented care on each
page in the chart. |
| Medication Allergies or NKA (N, S) |
Clearly identify all medication allergies in the patient's record. If
no allergies, make sure the chart shows "NKA" (for "no known allergies").
This step helps ensure therapeutically safe and effective prescription
medications. |
| Informed Consent (J, O) |
Providers must obtain informed consent of the patient, or if
applicable, the patient’s representative, before administering anesthesia
and or performing surgery. |
| Medical (J, O, N, S), Family (O) & Social (O, N) Histories as
Applicable |
Medical, family and social histories provide valuable information for
developing a planned course of treatment and care. Make sure the
historical information is appropriate for the procedure and patient.
Document the history in the patient’s medical record before administering
anesthesia or performing surgery. |
| Physical Exam (J, O, N, S) |
Thorough physical examinations establish a baseline for providing
healthcare. Make sure the physical exam is appropriate for the procedure
and the patient. Document the physician exam in the patient’s medical
record before administering anesthesia or performing surgery. |
| Progress Note/ Discharge Note Physical Exam Findings (O, N, S) |
Document the physical exam findings so they can be used to plan a
course of treatment and care. |
| Discharge Instructions (J, O) |
Clearly document these instructions to appropriately guide the
patient during the post-operative period following discharge. |
| Physician Discharging Patient Identified (J, O) |
Identify the licensed independent practitioner who has appropriate
privileges, is familiar with the patient, and is responsible for the
decision to discharge the patient.
|
| All Entries are Legible |
Clearly and legibly write all patient record entries so others can
read them. |
| All Entries are Dated and Signed |
Make sure all medical record entries identify the author via
handwritten signature, an initialed stamped signature, or a unique
electronic identification method.
Dated and signed entries:
1.) Prevent potential confusion should questions arise regarding the
authenticity of the documentation in the medical record, and
2.) Validate the information source if it becomes necessary to transfer
records. If authors use initials instead of signatures, the office must
keep a signature register on file. If the office uses an electronic
charting systems, take care to password-protect the electronic
signature.
|
Lab/Radiology/Consult Reports Present (J), Dated (N),
and Signed (N)
|
The physician should date and sign (or initial) all lab,
radiology, and pathology reports to demonstrate timely review. If the
physician initials are used instead of signatures, the office must keep a
signature register on file. Make sure lab, radiology and pathology
documentation is appropriate for the procedure and the patient.
|
Abnormal Results Notes/ Follow-up Plans (N)
|
It is essential to take the appropriate actions to
address abnormal laboratory, radiology, and or pathology reports.
|
Operative Notes (J, M, S):
Procedure (J, O)
Surgeon (J, O)
Assistant (J, O)
Pre-Operative Diagnosis (O)
Post-Operative Diagnosis (J, O)
Nurse Staff (O)
Duration of Procedure (O)
Any Unusual Problems or Occurrences (O)
Surgeon's Description of Tissue Removed (J, O)
Needle Count (S)
Dated and Signed (N)
|
Dictate or write the operative notes in the medical
record immediately after the surgery. These notes provide an accurate
record of the surgical procedure.
|
Anesthesia/Sedation Record:
Pre-Anesthesia Evaluation (J)
Anesthetic Sedation (J, O)
Dose of Anesthetic Sedation (J, O)
Duration of Anesthetic Sedation (PH)
Procedure (O)
Pertinent Information Related to Results or Reactions (O)
Anesthesiologist Anesthetist (O)
Dated and Signed (N)
|
Complete the anesthesia record prior, during and
following the procedure to provide an accurate record of the anesthesia
administered to the patient.
|
Nurses' Notes:
Pre-Operative Vitals (O)
Post-Operative Vitals (O)
Relevant Observations (O)
Patient's Condition on Discharge (O)
Dated (N) and Signed (O)
|
Include vital signs and all pertinent observations
relevant to patient and procedure.
|
Doctor's Orders (O)
Dated (N)
Signed (N)
|
The doctor's orders should be
appropriate to the patient's physical exam findings and condition.
|
