HCR 210 Week 4 Patient Reports

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HCR 210 Week 4 Patient Reports
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 ReportBrief Description of ContentsWho Signs the ReportFiling Standard
Face Sheet

 

Patient identification, financial data, clinical information (admitting and final diagnoses)

 

Attending physician30 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 ExaminationThe patient’s chief complaint, present illness history, past history, family history, social history, current medications, and review of systemsStaff member who directly obtained this information from the patientVariable between JCAHO and AOA, but usually not more than 7 days before or 48 hours after admission

 

Consultation Reports

 

Physician Orders

 

Progress NotesNotes about ongoing care: changes in the patient, complications, consultations, and treatmentStaff 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 physicianA.   Prior to surgery

B.    Immediately after surgery

C.    24 hours after surgery

 

Pathology Report

 

Recovery Room Record

 

Ancillary Testing Reports