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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