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 |Attending physician |30 days following patient | | |information (admitting and final diagnoses) | |discharge | |Advanced Directives |States what patients whishes are concerning their end of |The patient usually sign the |It’s upon admission. | | |life care. |report.
| | |Informed Consent |Patient is advised of treatment option and possible |The physician and the |Before procedures are | | |affects of treatment. |patient. |performed. | |Patient Property Form |List of patient belongings which was with the patient upon|Patient and admitting staff |(Not stated in the text, but | | |arrival at medical center. |center. |probably at the time property | | | | |is taken from the patient) | |Discharge Summary |States instructions that were given to the patient upon |Attending physician |Within 30 days of discharge.
| | |release from care. | | | |History and Physical |The patient’s chief complaint, present illness history, |Staff member who directly |Variable between JCAHO and | |Examination |past history, family history, social history, current |obtained this information |AOA, but usually not more than| | |medications, and review of systems |from the patient |7 days before or 48 hours | | | | |after admission | |Consultation Reports |Includes consultants opinions and findings on patient |The Physician |Within 48 hours | | |care.
| | | |Physician Orders |Directs the care a patient receives |The physician |Immediately after the visit. | |Progress Notes |Notes about ongoing care: changes in the patient, |Staff who see the patient |At the time they occur | | |complications, consultations, and treatment |sign and attending physician | | | | |countersigns | | |Anesthesia Record |Records amount of anesthesia given to patient lists any |The anesthesiologist.
|Not more than 24 hours after | | |problems from anesthesia if any. | |the surgery. | |Operative Report |History, physical exam, lab and X-ray exams, and |Surgeon or attending |Prior to surgery | | |preoperative diagnosis |physician |Immediately after surgery | | |Therapeutic procedures | |24 hours after surgery | | |Postoperative evaluation | | | |Pathology Report |Analyzes tissue to assist in diagnosis and treatment.
|Pathologist |As soon as possible after | | | | |report is complete. | |Recovery Room Record |List care given to patient in recovery room. |Anesthesiologist |At time of release from | | | | |recovery room. | |Ancillary Testing |Date, time labs are receive time results are determined. |Laboratory tech. |At time of receipt of sample. | |Reports | | | |