hcr210r4 appendix c patient reports
Associate Level Material
Appendix C
Acute Care Patient Reports
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
is a legal document in which patients provide instructions as to how they want to be treated in the event they become very ill and there is no reasonable hope for recovery.
The patient
Upon admission
Informed Consent
The process of advising a patient about treatment options and, depending on state laws, the provider may be obligated to disclose a patient’s diagnosis, proposed treatment/surgery, reason for the treatment/surgery, possible complications, likelihood of success, alternative treatment options, and risks if the patient does not undergo treatment/ surgery.
The patient
Whenever applicable
Patient Property Form
Records of items patients bring with them to the hospital.
Hospital staff
(Not stated in the text, but probably at the time property is taken from the patient)
Discharge Summary
Must fully and accurately describe the patient’s condition at the time of discharge, patient education when applicable, including instructions for self-care, and that the patient/responsible party demonstrated an understanding of the self-care regimen.
By attending physician
When patient is getting ready to be 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
Appendix C
Acute Care Patient Reports
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
is a legal document in which patients provide instructions as to how they want to be treated in the event they become very ill and there is no reasonable hope for recovery.
The patient
Upon admission
Informed Consent
The process of advising a patient about treatment options and, depending on state laws, the provider may be obligated to disclose a patient’s diagnosis, proposed treatment/surgery, reason for the treatment/surgery, possible complications, likelihood of success, alternative treatment options, and risks if the patient does not undergo treatment/ surgery.
The patient
Whenever applicable
Patient Property Form
Records of items patients bring with them to the hospital.
Hospital staff
(Not stated in the text, but probably at the time property is taken from the patient)
Discharge Summary
Must fully and accurately describe the patient’s condition at the time of discharge, patient education when applicable, including instructions for self-care, and that the patient/responsible party demonstrated an understanding of the self-care regimen.
By attending physician
When patient is getting ready to be 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