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 information (admitting and final diagnoses)
Attending physician
30 days following patient discharge
Advanced Directives
Patients over the age of 18 have the right to provide instructions on how they want to be treated in case they get very sick and there is no hope for their recovery. Patient, physcian
Vary depending on the state
Informed Consent
Informing the patient of treatment options. They need to sign informing that they are are aware of what is going to be done for treatment. Physician. Patient.
Not stated in text but for every procedure or treatment
Patient Property Form
Records items that patients bring with them into the hospital to ensure they receive everything back. Hospital staff member and patient
(Not stated in the text, but probably at the time property is taken from the patient)
Discharge Summary
Document stating what patient was treated for what procedures were performed, treatment and condition @ discharge and information provided to the patient and family. physician
Right after release
History and Physical Examination
The patient’s chief complaint, present illness history, past history, family history, social history, current medications, and review of systems 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
Consultation Reports
Consultant’s opinion and findings based on a physical review of the patient and their medical record and give their recommendation or opinion. Consulting physician.
Text does not state.
Physician Orders
Documentation of the orders given to the patient by the physician for continuous care. Either follow up or medication. Physician
Within a time frame specified by the facility
Progress Notes
Notes about ongoing care: changes in the patient, complications, consultations, and treatment Staff who see the patient sign and attending physician
At the time they occur
Anesthesia Record
Documentation of patient while and during administration of moderate or deep sedation or anesthesia and progress notes. Individual qualigied to adminster anesthesia.
No later than 48 hours after surgery.
Operative Report
A. History, physical exam, lab and X-ray exams, and preoperative diagnosis B. Therapeutic procedures
C. Postoperative evaluation
Surgeon or attending physician
A. Prior to surgery
B. Immediately after surgery
C. 24 hours after surgery
Pathology Report
Documents the analysis of tissue removed surgically or diagnostically or that was expelled by the patient. Pathologist
As soon as completed usally within 24 hours.
Recovery Room Record
Record postoperative vital sgns and level of consciousness, medication and blood components administered IV fluids and drugs administered. Any complications. Nurse
Text doesn’t state.
Ancillary Testing Reports
Assist physicians in diagnosis and treatment of patients. Gives results as well as treatment plans. Person performing tests.
As soon as interpretation has been made usually within 24 hours