DOCUMENTATION CHECK LIST FOR 4B
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DOCUMENTATION CHECK LIST FOR 4B. ADMISSION DOCUMENTATION. HISTORY AND PHYSICAL SENIOR ADMISSION NOTE CARE PLAN EDUCATION (write “see edu in HPI” and then remember to fill edu field in HPI note) 24 HR DISCHARGE NOTICE PT. SAFETY CARDS RECONCILE MEDICATION AND PROBLEM LIST.
DOCUMENTATION CHECK LIST FOR 4B
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Presentation Transcript
ADMISSION DOCUMENTATION • HISTORY AND PHYSICAL • SENIOR ADMISSION NOTE • CARE PLAN • EDUCATION (write “see edu in HPI” and then remember to fill edu field in HPI note) • 24 HR DISCHARGE NOTICE • PT. SAFETY CARDS • RECONCILE MEDICATION AND PROBLEM LIST
PROGRESS NOTE DOCUMENTATION • DAILY PROGRESS NOTE • EDUCATION FIELD WITHIN THE PROGRESS NOTE TEMPLATE
PROCEDURE DOCUMENTATION • CONSENT: RISKS, BENEFITS, ALTERNATIVES, RISKS AND BENEFITS OF ALTERNATIVES, DATED, TIMED, SIGNED BY PHYSICIAN(only PGY-2/3), WITNESS, PARENT • TIME OUT SHEET • PROCEDURE NOTE • LABEL SAMPLES BY PATIENT’S SIDE • ADEQUATE ISOLATION PRECAUTIONS WHILE PERFORMING PROCEDURE
DISCHARGE DOCUMENTATION • DISCHARGE SUMMARY • DISCHARGE EDUCATION • VNS • ASTHMA ACTION PLAN • PRESCRIPTIONS • DISCHARGE ORDER • SCHOOL/WORK NOTE • MEDICATION RECONCILIATION • PROBLEM LIST RECONCILIATION • SCHOOL EDUCATION FORM (where applicable)
