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Associate Level 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 patients record. Four of the reports have been done for you. Name of Report Face Sheet Brief Description of Contents Patient identification, financial data, clinical information (admitting and final diagnoses) Health care proxy, living will, medical power of attorney Who Signs the Report Attending physician Patient Filing Standard 30 days following patient discharge Not stated in the text, Probably 30 days following patient discharge. Probably 30 days following patient discharge (Not stated in the text, but probably at the time property is taken from the patient) Within 30 days of discharge

Advanced Directives

Informed Consent Patient Property Form

Process of advising a patient about treatment options, risks, and benefits of treatment. Records the patients bring with them to the hospital.

Patient and physician Hospital staff member and patient.

Discharge Summary

Patients hospitalization, including reason for hospitalization, course of treatment, condition at discharge, patient and facility identification and admission and discharge dates. History and The patients chief complaint, Physical present illness history, past history, Examination family history, social history, current medications, and review of systems

Attending physician

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 Not stated in the
HCR 210

Consultation Consultants opinion and findings

Attending

Reports

based on physical examination and review of patient records. Medications and dosages

physician and consulting physician Registered nurse

Physician Orders

Progress Notes

Notes about ongoing care: changes in the patient, complications, consultations, and treatment Preanesthesia medication administered, including time, dosage, and effect on patient. Appraisal of any changes in patients condition. Patients vital signs. Any blood loss. Iv fluids, transfusions including amount, technique used, duration. A.History, physical exam, lab and X-ray exams, and preoperative diagnosis B.Therapeutic procedures C.Postoperative evaluation

Staff who see the patient sign and attending physician countersigns

text but probably at the time of checkout or discharge Not stated in the text but probably at the time of checkout or discharge At the time they occur

Anesthesia Record

Anesthesiologist 48 hours after or Anesthesia surgery agent administered

Operative Report

Surgeon or attending physician

A. Prior to surgery B. Immediate ly after surgery C. 24 hours after surgery Within 24 hours

Pathology Report

Recovery Room Record Ancillary Testing Reports

Date of examination, clinical diagnosis, and tissue examined pathologic diagnosis, macroscopic examination, and microscopic examination. Patients condition upon arrival to recovery room, postoperative care given, level of consciousness upon entering and leaving recovery room, monitoring of vital signs. Test results from laboratories, radiology, and nuclear medicine.

Pathologist

Responsible physician or certified registered nurse. Person performing the test reports

At discharge from recovery

As soon as an interpretation has been made. Usually within 24 hours


HCR 210

HCR 210

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