Axia College 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 Brief Description of Contents Who Signs the Filing Standard

Report Report
Face Sheet Patient identification, financial Attending 30 days following
data, clinical information (admitting physician patient discharge
and final diagnoses)

Advanced States what patients wishes are Patient Upon admission

Directives concerning their end of life care

Informed Patient is advised of treatment Phhsicion and Before

Consent option and possible affects of patient procedures are
treatment performed
Patient List of patient belongings which Patient and (Not stated in the
Property was with the patient upon arrival at admitting staff text, but probably
Form medical center member at the time
property is taken
from the patient)

Discharge States instructions that were given Attending Within 30 days of

Summary to the patient upon release from physician discharge
care
History and The patient’s chief complaint, Staff member Variable between
Physical present illness history, past history, who directly JCAHO and
Examination family history, social history, obtained this AOA, but usually
current medications, and review of information from not more than 7
systems the patient days before or 48
hours after
admission

Consultation Includes consultants opinions and Physician Within 48 hours

Reports findings on patient care

Physician Directs the care a patient receives Physician Immediately after

Orders visit

HCR 210
Progress Notes about ongoing care: Staff who see At the time they
Notes changes in the patient, the patient sign occur
complications, consultations, and and attending
treatment physician
countersigns

Anesthesia Records amount of anestheia Anestesiologist Not more than24

Record given to patient, lists any problems hours after
from anestesia if any. surgery.
Operative A.History, physical exam, lab and Surgeon or A. Prior to
Report X-ray exams, and preoperative attending surgery
diagnosis physician B. Immediate
B.Therapeutic procedures ly after
C.Postoperative evaluation surgery
C. 24 hours
after surgery

Pathology Analyzes tissue to assist in Pathologist As soon as

Report daignosis and treatment possible after
report is
complete.
Recovery List care given to patient in Anesthesiologist At time of release
Room recovery room or CRNA from recovery
Record room.

Ancillary Date,time labs are received,time Laboratory tech At time of receipt

Testing results are determined, of sample
Reports

HCR 210