Contents of Patient Medical Record

POLICY:
 
The inclusion in the medical record of specific patient data 
in a logical and uniform manner is necessary to assure that 
quality patient care is rendered; the patient medical record 
will be completed including all signatures within 14 business 
days.  
PROCEDURE:
 
1.  Each patient chart shall contain the following, as 
    appropriate:
 
   A.   Patient's personal information (face sheet, etc) to 
        include at least the following demographics: name, 
        address, phone number, identification number, if 
        appropriate, date of birth, height and weight, sex, 
        name of responsible party or legally authorized 
        representative, etc.) The Patient's language and 
        communication needs if any.
   B.   Referrals
   C.    Documentation of history and physical examination
   D.    Reports of diagnostic tests, if ordered 
   E.    Working diagnosis
   F.    Anticipated date for follow-up appointment
   G.    Informed consent for treatment 
   H.    Consent for treatment by others (anesthesia 
provider, etc.)
   I.    If procedure is performed:
          1.    Medical clearance if requested
          2.    Blood work or other testing if requested
          3.    Preoperative instructions
          4.    Consent (doctor/facility/anesthesia)
          5.    Preoperative evaluation indexed to
anticipated level of anesthesia – on day of 
                procedure
          6.    Use of the universal protocol; verification
                of correct patient, site, consent, markings, 
                implants, equipment, and time out taken.
          7.    Medication reconciled across the continuum
          8.    Documentation of patient being handed over 
                to another provider of care within the 
                organization (anesthesia provider etc.)
          9.    Circulating record if appropriate
          10.    Anesthesia record (by anesthesia provider)
          11.    Sedation record if dentist or physician 
                doing sedation
          12.    Short descriptive operative note in progress 
                note plus,(  If the physician's operative 
                report will be dictated and will not appear 
                as real time document, a note will be placed
                in the chart immediately after surgery 
                indicating the following:  name of the 
                primary surgeon, and assistants, procedure(s)
                performed, and description of each 
                procedure, findings, estimated blood loss, 
                specimens removed and post operative 
                diagnosis.  
          13.    Operative report
          14.    Recovery room record, if appropriate
          15.    Physician discharge signature
          16.    Postoperative instructions and information 
                regarding medications prescribed form
                (receipted by patient and caregiver)
          17.    Documentation of post-procedure follow-up 
                telephone call
          18.    Pathology report, initialed if appropriate
          19.    Copies or consistent notation of any 
                prescriptions given, at anytime during the 
                peri-operative period; i.e. Medication 
                Reconciliation.
*If performing in house CLIA waived testing please refer to  
Volume 3, OT.1 for documentation of this testing.
 
2.  History and physical shall be available on the patient 
    chart prior to the start of the procedure. The history 
    and physical examination shall be adequate to support 
    the chief complaint and the planned intervention 
    including:
 
    - documentation of the necessity for intervention, 
    - a brief medical history of the patient appropriate to 
      the planned intervention, 
    - a summary of the findings of a pre-operative physical 
      examination, 
    - documentation of known ALLERGIES, 
    - a listing of current medications, with times and   
      dosages and 
    - a description of the procedure planned.
 
3.  Reports of any tests ordered pre-operatively shall be 
    available prior to start of the procedure.  Abnormal 
    results will be acknowledged as a part of the dictated
    or written operative notes in the chart.
 
4.  The signed consent will identify the patient, all 
    physicians, and the planned procedure.  The patient or 
    legal guardian must sign the consent prior to surgery; 
    the signature should be witnessed.
The informed consent form will document the patient's 
    permission for and understanding of:
 
    A.  The procedure to be performed;
    B.  The medical staff member to perform the procedure;
    C.  An assistant, if applicable, to assist with the 
        procedure; 
    D.  The anesthesia provider, if applicable, to 
        administer anesthesia; and,
    
    If the anesthesia provider uses a separate consent form, 
    that form will document the patient's permission for the 
    anesthesia provider to administer anesthesia.
    
    Evaluation shall be completed by the anesthesia provider 
    prior to surgery. The anesthesia record shall document 
    all treatment and care rendered to the patient at the 
    time of the procedure.  It will list medications, 
    anesthetic agents, results of regular monitoring of 
    vital signs, intubation data, surgical times, name of 
    surgical procedure, IV administration, and any 
    complication and treatment.
 
    If the patient is unable to read and/or understand the 
    English language, a staff member or interpreter may 
    translate the consent to the patient.  The signed 
    consent remains on the patient's medical record.
 
5.  The organization utilizes peri-operative paper work that 
    documents the following: sections 1-19 above, as 
    applicable.
 
    The patient's post-operative condition will be charted
prior to discharge.
  
    Physicians' orders must be signed and will include 
    appropriate pre-, post- and intra-operative orders and 
    prescriptions.  
   
    If the physician's operative report will be dictated and
    will not appear as a real time document a note will be 
    placed in the chart immediately after surgery indicating 
    the following:  name of the primary surgeon, and 
    assistants, procedure(s) performed, and description of
    each procedure, findings, estimated blood loss, 
    specimens removed and post operative diagnosis.  However 
    during the dictation, the preceding should also be  
    noted.  The condition of the patient at discharge from 
    the OR--whether a direct discharge out of this facility 
    or to another level of care, will also be recorded. 
   
    When used, the post-operative/recovery room record will 
    describe all care given, post-operatively, including 
    vital signs, medications, wound status, and respiratory 
    status, whether in the Operating Room, the procedure 
    room, or the recovery room.  IV volumes, level of 
    consciousness, and any significant events will be 
    documented.  This record will be signed by the 
    responsible nurse and remain as part of the patient's 
    medical record.
 
    Written discharge instructions will be given to each 
    patient or care giver, including information regarding 
    diet, when appropriate,  ambulation, medication (if any),
    time of follow-up appointment, and information regarding 
    actions to take in case of an emergency.
 Pathology report, if requested by surgeon, will be 
    generated by the pathology group; the report will be 
    returned within seven business days of receipt of 
    specimen.  If tissue has been sent to an outside lab for 
    further evaluation, this should be documented on a 
    report from the pathologist.

Approved By Governing Board    
PR.3    
Control #16.10
GUPTA GASTRO