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    Medical Record Review Form

    Uploaded by

    Simon Dzokoto
    The document is a medical record review form that contains criteria to evaluate whether a patient's medical records meet documentation standards. It includes sections to document patient information, admission and discharge details, informed consent, medical history, physical exams, treatment plans, procedures, and post-operation notes. It also contains a separate form to collect data on the accessibility of medical records based on how quickly staff can locate records.

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    Download as DOC, PDF, TXT or read online from Scribd

    Medical Record Review Form

    Uploaded by

    Simon Dzokoto
    3K views3 pages
    The document is a medical record review form that contains criteria to evaluate whether a patient's medical records meet documentation standards. It includes sections to document patient information, admission and discharge details, informed consent, medical history, physical exams, treatment plans, procedures, and post-operation notes. It also contains a separate form to collect data on the accessibility of medical records based on how quickly staff can locate records.

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    The document is a medical record review form that contains criteria to evaluate whether a patient's medical records meet documentation standards. It includes sections to document patient information, admission and discharge details, informed consent, medical history, physical exams, treatment plans, procedures, and post-operation notes. It also contains a separate form to collect data on the accessibility of medical records based on how quickly staff can locate records.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    3K views3 pages

    Medical Record Review Form

    Uploaded by

    Simon Dzokoto
    The document is a medical record review form that contains criteria to evaluate whether a patient's medical records meet documentation standards. It includes sections to document patient information, admission and discharge details, informed consent, medical history, physical exams, treatment plans, procedures, and post-operation notes. It also contains a separate form to collect data on the accessibility of medical records based on how quickly staff can locate records.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    Medical Record Number: __________________ Attending Doctor: _______________________ Admission Date: ________________________ Discharge Date: __________________________ Reviewer: ____________________________

    Date: _________________________________ CRITERIA Y N N/A

    Medical Record Review Form

    Informed consent for treatment signed by patient Past medical history and history of present illness Documented within 24 hours of admission and prior to surgery: Past history, etc. contains: Chief complaint Medical history Family history Social status Review of symptoms Physical examination Treatment plan Initial nursing plan documented within 24 hours of admission Progress notes documented daily, signed and dated Pre-anaesthesia assessment documented, signed and dated Surgery/procedure performed documented, signed and dated Post-operative monitoring of patient in Recovery room Operation report documented immediately following surgery: Operation report includes:

    Procedure Findings Specimen(s) removed Postoperative diagnosis Discharge note recorded in progress notes on day of discharge:

    Discharge note includes: Condition on discharge Final diagnosis Prognosis Follow-up details Discharge summary completed by attending doctor: Discharge summary includes: Summary of hospitalization Treatment and medications Final diagnosis (principal) Associated diagnoses Procedures Prognosis and follow-up

    CRITERIA YES NO 1. Does it take staff more than 5 minutes to locate a medical record in the permanent file? 2. Does it take staff more than 5 minutes to locate an incomplete medical record? 3. If a medical record is not on file, is a tracer or outguide in its place? 4. Are names and numbers correctly and legibly written on folders? 5. Are stacks of medical records found lying on desks and in no order? 6. Does the medical record department/office have a procedure for medical record location?

    Simple Data Collection Form for a Manual Medical/Health Record Tracking System Accessibility of Records Criteria

    COMMENT

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