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 |Health care proxy, living will, medical power of |Patient |Upon admission | | |attorney. Provides instructions as to how someone wants | | | | |to be treated in the event they become too ill.
| | | |Informed Consent |Explanation of the risks and benefits of a treatment or |Patient and attending |Before anesthesia and | | |procedure, alternatives to the treatment, and evidence |physician with date and time. |performance of any surgical | | |that the patient or legal guardian understands and | |procedure. | | |consents to undergo treatment. | | | |Patient Property Form |Records items patients bring with them to the hospital.
|Patient and hospital staff |(Not stated in the text, but | | | |member. |probably at the time property | | | | |is taken from the patient) | |Discharge Summary |Documents the patient’s hospitalization, including |Attending physician |Within 30 days of discharge | | |reasons for hospitalization, course of treatment, and | | | | |condition at discharge. Also includes patient and | | | | |facility identification, admission and is charge dates.
| | | |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 from|AOA, but usually not more than| | |medications, and review of systems |the patient |7 days before or 48 hours | | | | |after admission | |Consultation Reports |Includes the consultant’s opinions and findings based on|Attending physician |Does not state in the book, | | |a physical examination and review of patient records.
| |But I would assume it must be | | | | |filed as soon as the attending| | | | |physician request a | | | | |consultation. | |Physician Orders |Contain diagnostic and therapeutic patient care |physician |Within a time frame specified | | |activities | |by the facility | |Progress Notes |Notes about ongoing care: changes in the patient, |Staff who see the patient sign|At the time they occur | | |complications, consultations, and treatment |and attending physician | | | | |countersigns.
| | |Anesthesia Record |Preanesthesia medication administered, including time, |Anesthesiologist |AOA requires a preoperative | | |dosage, and effect on patient. Appraisal of any changes | |evaluation within 48 hours | | |in the patient’s condition. Anesthesia agent | |before surgery.
Postoperative | | |administered, patients vital signs, any blood loss, | |filed not more than 24 hours | | |transfusions administered, IV fluids administered, | |after surgery | | |patients condition throughout surgery | | | |Operative Report |History, physical exam, lab and X-ray exams, and |Surgeon or attending physician|Prior to surgery | | |preoperative diagnosis | |Immediately after surgery | | |Therapeutic procedures | |24 hours after surgery | | |Postoperative evaluation | | | | | | | | |Pathology |Date of examination, clinical diagnosis, tissue |Pathologist |As soon as completed, usually | |Report |examined, | |within 24 hours.
| | |Pathologic diagnosis, macroscopic examination, and | | | | |microscopic examination. | | | | | | | | |Recovery Room Record |Patient’s general condition upon arrival to recovery |Dated and timed by the |As soon as the patient is | | |room, postoperative and post anesthesia care given, |responsible physician |discharged from the recovery | | |patient’s level of consciousness upon entering and |(anesthesiologist) or |room. | | |leaving, description of presence/absence of anesthesia |certified registered nurse | | | |related complications, monitoring of patient vital |anesthetist.
| | | |signs, documentations of infusions, surgical dressings, | | | | |tubes, catheters, and drains. Written order releasing | | | | |patient from recovery room. | | | |Ancillary Testing |Reports of pathology and clinical laboratory |Signed or initialed by the |Usually within 24 hours | |Reports |examinations, radiology and nuclear medicine |person performing the test | | | |examinations or treatments, anesthesia records, and any | | | | |other diagnostic or therapeutic procedures. | | |.