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This document contains a checklist of items that should be included in a patient's medical records at admission and discharge. The checklist includes sections for demographic information, admission and discharge details, physical exam records, lab results, doctor's orders, progress notes, discharge summary, temperature/pulse/respiration records, intravenous records, medication records, and nurses' notes. The document emphasizes correctly and completely filling out each item without erasures by lining out incorrect entries and writing the correct entry above with a signature.
This document contains a checklist of items that should be included in a patient's medical records at admission and discharge. The checklist includes sections for demographic information, admission and discharge details, physical exam records, lab results, doctor's orders, progress notes, discharge summary, temperature/pulse/respiration records, intravenous records, medication records, and nurses' notes. The document emphasizes correctly and completely filling out each item without erasures by lining out incorrect entries and writing the correct entry above with a signature.
This document contains a checklist of items that should be included in a patient's medical records at admission and discharge. The checklist includes sections for demographic information, admission and discharge details, physical exam records, lab results, doctor's orders, progress notes, discharge summary, temperature/pulse/respiration records, intravenous records, medication records, and nurses' notes. The document emphasizes correctly and completely filling out each item without erasures by lining out incorrect entries and writing the correct entry above with a signature.
] Patients name [ ] MR#[ ] Address [ ] Demographic data: complete [ ] incomplete [ ] D. admission [ ] D. discharge [ ] Admitting officer [ ] Admitted DX [ ] Final DX [ ] ICD Code [ ] Disposition [ ] P.E Record [ ] History of present illness [ ] General survey [ ] V/S [ ] Personal History [ ] Past Medical History [ ] Review of systems [ ] Family history [ ] Consent Form [ ] Signed Consent to Care [ ] Date Signed [ ] DAMA [ ] Signed Acknowledgement of Responsibility [ ] Date [ ] Laboratory Results [ ] Complete [ ] Incomplete [ ] Doctors Orders Sheet [ ] Date [ ] Time [ ] Doctors Signature [ ] Date & Time noted [ ] R.N Signature [ ] Progress Notes [ ] Date [ ] Time [ ] Doctors Signature [ ] Discharge summary [ ] Date Admitted [ ] Date Discharge [ ] Attending Physician [ ]Admitting DX [ ] Final DX [ ] C/C [ ] Brief Clinical History &Pertinent P.E [ ] Lab. Findings [ ] Course in the Ward [ ] Disposition [ ] Date Accomplished [ ] R.O.D sign [ ] TPR Sheet [ ] Date [ ] NHD [ ] complete TPR graph [ ] B.P [ ] Wt. [ ]Urine [ ] Stool [ ] NOD sign [ ] Intravenous Sheet [ ] Date [ ] Bot.# [ ] Kind of Soln. [ ] Drop/ Drip Factor [ ]Time Started [ ] Volume [ ] Nurse Sig. [ ] Medication Sheet [ ] Date [ ] NHD [ ] Medications : Generic Name [ ] Brand Name [ ] Frequency [ ] Dose [ ] Time Element [ ] NOD sign [ ] Nurses Notes [ ] Date [ ] Shift [ ] Time [ ] Diet [ ] NOD sign [ ] M.R. Checklist Date Accomplished: ______________ Signature of Personnel In-charge: _______________
Note: Each page of the Medical Record must
have complete patients name, date admitted, sex, and age. All spaces must be filled up correctly. No erasures please. But if you made a wrong entry do not use correction fluid to erase it rather make a single line over the wrong entry, write the correct entry above it and sign. Thank you. The MR Management.
MMC MEDICAL RECORDS CHECKLIST
ADMISSION AND DISCHARGE RECORD [
] Patients name [ ] MR#[ ] Address [ ] Demographic data: complete [ ] incomplete [ ] D. admission [ ] D. discharge [ ] Admitting officer [ ] Admitted DX [ ] Final DX [ ] ICD Code [ ] Disposition [ ] P.E Record [ ] History of present illness [ ] General survey [ ] V/S [ ] Personal History [ ] Past Medical History [ ] Review of systems [ ] Family history [ ] Consent Form [ ] Signed Consent to Care [ ] Date Signed [ ] DAMA [ ] Signed Acknowledgement of Responsibility [ ] Date [ ] Laboratory Results [ ] Complete [ ] Incomplete [ ] Doctors Orders Sheet [ ] Date [ ] Time [ ] Doctors Signature [ ] Date & Time noted [ ] R.N Signature [ ] Progress Notes [ ] Date [ ] Time [ ] Doctors Signature [ ] Discharge summary [ ] Date Admitted [ ] Date Discharge [ ] Attending Physician [ ]Admitting DX [ ] Final DX [ ] C/ [ ] Brief Clinical History &Pertinent P.E [ ] Lab. Findings [ ] Course in the Ward [ ] Disposition [ ] Date Accomplished [ ] R.O.D sign [ ] TPR Sheet [ ] Date [ ] NHD [ ] complete TPR graph [ ] B.P [ ] Wt. [ ]Urine [ ] Stool [ ] NOD sign [ ] Intravenous Sheet [ ] Date [ ] Bot.# [ ] Kind of Soln. [ ] Drop/ Drip Factor [ ]Time Started [ ] Volume [ ] Nurse Sig. [ ] Medication Sheet [ ] Date [ ] NHD [ ] Medications : Generic Name [ ] Brand Name [ ] Frequency [ ] Dose [ ] Time Element [ ] NOD sign [ ] Nurses Notes [ ] Date [ ] Shift [ ] Time [ ] Diet [ ] NOD sign [ ] M.R. Checklist Date Accomplished: ______________ Signature of Personnel In-charge: _______________
Note: Each page of the Medical Record must
have complete patients name, date admitted, sex, and age. All spaces must be filled up correctly. No erasures please. But if you made a wrong entry do not use correction fluid to erase it rather make a single line over the wrong entry, write the correct entry above it and sign. Thank you. The MR Management.