HITT 1401 -Lab chart review

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Author:
lorenb2k
ID:
180626
Filename:
HITT 1401 -Lab chart review
Updated:
2012-10-29 19:01:12
Tags:
110712
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Description:
110712
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  1. Admission record/facesheet
    • Name of form
    • Patinet age/DOB
    • Attending physician
    • Admitting/Principal diagnosis
    • Physician name and signature, w/Date/Time
  2. Discharge summary
    • Name of form
    • Admitting Dx
    • Discharge Dx
    • Inpatient Hx
    • Admitting/Principal diagnosis
    • Physician name and signature, w/date/time
  3. Informed consent form
    • Name of form
    • Patient name
    • Admission date
    • Legal representative
    • Witness signature
    • Attending physician name and signature, w/date/time
  4. History and Physical form
    • Chief complaint
    • Admitting/Principal Dx
    • Past medical Hx
    • Personal Hx
    • Family Hx
    • Record of physician's findings
    • Attending physician name and signature, w/date/time
  5. Dr. progress notes
    • Admitting note
    • Date, time, entry for each day
    • Attending physician name and signature, w/date/time
  6. Doctor's orders
    • State type of order: Written, verbal, standing (patinet specific), or automatic (narcotics etc...)
    • Attending physician name and signature, w/date/time
  7. Radiology Report
    • Title of form
    • Pt name and info
    • Reason for x-rays
    • Time of dosage
    • Findings
    • Radiologist name and signature, w/date/time
  8. Laboratory report
    • Type of labs
    • Date/time ordered (*see Drs order)
    • Results which may indicate low/high findings
  9. Graphic record (TPR report) temperture, respiration and pressure)
    Daily results of fluid in/out take
  10. Medication Record
    • List allergies to medication
    • Medications (dosage/route/time)
    • Initials and siganture of med assistants
  11. PRN mean:
    • "Pro re nata"
    • As needed
    • or
    • As circumstances arises
  12. Nurse's notes
    • EACH NOTE:
    • Daily entry (frequently)
    • List of treatments and notes w/date/time
    • also Discharge note
    • RN name and signature, w/date/time
  13. Nurse's Discharge summary form
    • Patient name and details
    • Vitals
    • Medications
    • Instructions to family
    • D/C time
    • Comments
    • RN name and signature, w/date/time
  14. Patient Property Record form
    • 1. Statement to store personal items safely
    • 2. Statement to store patient money/valuables safely
    • 3. Statement to dispose, store or administer of  patient medications as recommend by personal physician

    • Patient signature, date/time on each section
    • Assisting staff name and signature, w/date/time

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