Assembling Charts
Properly assemble inpatient. Assembly of medical records are done in * Chronological order according to “filing order of the medical record.” * Assemble forms according to the order given in this policy * Charts are identified with typewritten white labels with: 1) Patient Name 2) Electronic Health Record Number (MRN)
Order of Chart Assemble 1. Face sheet * Patient Information and Guarantor 2. Consent Forms * Signed Yearly Consent Form * Medicare Consent Forms * Counseling Form * BC Consent
3. Lab Reports * Pathology Reports * Laboratory Reports 4. Prenatal (Only Pregnant Patients) 5. Hospital DC * All hospital discharges including ER visits 6. Cardiac * Echocardiography results * 12-Lead EKGs * Stress Test Results * Cardiac catherization results * Venous & / or Arterial Duplex results * All other heart related 7. Procedures * Biopsy * Op reports (colonoscopy, cholecystectomy, CABG, etc) * All procedures * Home Health Orders 8. Correspondence * Letters from consulting physicians 9. Medical History (Old Records) 10. Miscellaneous
I got to watch Mrs. Cathy as she reviewed charts for deficiencies. If any deficiencies are noted a note is put on the chart and the chart is returned to the physician to have all documentation correct or signed.
At 11 o’clock we had a staff meeting where all the staff, even those that work from home comes in and we reviewed VEH growth, scores, and what the department needs to be doing in the up coming weeks.
After lunch we started reviewing CD’s that have been created from past paper charts. The paper charts have been put on CD to help conserve space, and create a more secure source for saving ad storing past medical histories.
1. X-Rays * All X-Rays * Mammogram * CT Scans, MRIs
Order of Chart Assemble 1. Face sheet * Patient Information and Guarantor 2. Consent Forms * Signed Yearly Consent Form * Medicare Consent Forms * Counseling Form * BC Consent
3. Lab Reports * Pathology Reports * Laboratory Reports 4. Prenatal (Only Pregnant Patients) 5. Hospital DC * All hospital discharges including ER visits 6. Cardiac * Echocardiography results * 12-Lead EKGs * Stress Test Results * Cardiac catherization results * Venous & / or Arterial Duplex results * All other heart related 7. Procedures * Biopsy * Op reports (colonoscopy, cholecystectomy, CABG, etc) * All procedures * Home Health Orders 8. Correspondence * Letters from consulting physicians 9. Medical History (Old Records) 10. Miscellaneous
I got to watch Mrs. Cathy as she reviewed charts for deficiencies. If any deficiencies are noted a note is put on the chart and the chart is returned to the physician to have all documentation correct or signed.
At 11 o’clock we had a staff meeting where all the staff, even those that work from home comes in and we reviewed VEH growth, scores, and what the department needs to be doing in the up coming weeks.
After lunch we started reviewing CD’s that have been created from past paper charts. The paper charts have been put on CD to help conserve space, and create a more secure source for saving ad storing past medical histories.
1. X-Rays * All X-Rays * Mammogram * CT Scans, MRIs