Sl. No. Medical Records Forms & Components 1 Filing of records 2 Assembling and Coding of the record Record is legible; 3 Admission forms
3.1 Patient details entered 3.2 Reporting 3.3 Signature of the doctor 3.4 Corporate/TPA patient marked 3.5 Admission consent form Enrollees Name or ID# (Medicaid or Internal) included on all pages; Parent or Legal Guardian noted in record if applicable; Name of Emergency Contact & Phone Number noted in record; Primary language spoken, translation needs and communication assistance noted; Living Arrangement/Marital Status noted in record; 4 Consent forms 4.1 General consent form
4.1.1 Patient name with procedure 4.1.2 Signature of the patient with date 4.1.3 Signature of the doctor with date 4.1.4 Signature of the witness
4.2 Special Consent (n = 317)
4.2.1 Patient profile (IP no, Name, Bed no) 4.2.2 Name and signature of the patient 4.2.3 Signature of the witness with date 4.2.4 Signature of the performing doctor with date 4.2.5 Indication of surgery/procedure 7 Anesthesia Consent forms
7.1 Anesthetist, name, signature and date 7.2 Signature of the patient
8. Anesthesia Management Form
8.1 Patient profile documented 8.2 Signature of the doctor with name and date 8.3 Pre anesthetic assessment 8.4 Anesthesia used documented 8.5 Physiological changes of the patient 9. Postoperative forms
9.1 Post surgery psychological status 9.2 Post surgical medical description 9.3 Patient care planned and documented after surgery 9.4 Signature and date by the doctor 9.5 Pre operative diagnosis tallies with the post operative 10 Doctor’s record
10.1 Date, time and Signature 10.2 Making entries daily Case sheet documentation Each visit has documentation of chief complaint / purpose of visit; Clinical summary present with significant illnesses, surgery & medical conditions (past and present) updated and current; Allergies / Adverse Reactions or NKA noted; Past medical history for enrollee includes: tobacco use, ETOH, substance abuse, family history, psycho-social issues; History and Physical Exam is documented, including objective information; Lab, X-Ray, EKG and other studies ordered; Diagnosis / Medical Impression noted; Plan / Treatment consistent with diagnosis
Follow-up Plan noted for each encounter; Problems identified from previous visits addressed; Current list of medications is noted; 11 Nurse’s record
11.1 making daily entries 11.2 Date, time and signature 12 Discharge summary
12.1 Chief complaint, past history, physical examination 12.2 Medication and Treatment given 12.3 Condition at discharge 12.4 Date or time for next follow up 12.5 Discharge medication or any advice on the discharge 12.6 Signature of the doctor
