HCR 210 Week 4 Patient Reports

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HCR 210 Week 4 Patient Reports
Resources: Appendix C & Ch. 6 of Essentials of Health Information Management
Complete Appendix C.
Submit your completed Appendix C.
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, 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




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




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