week 4
Associate Level 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 Report
Brief Description of Contents
Who Signs the Report
Filing Standard
Face Sheet
Patient identification, financial data, clinical information (admitting and final diagnoses)
Attending physician
30 days following patient discharge
Advanced Directives
Patients over the age of 18 have the right to provide instructions on how they want to be treated in case they get very sick and there is no hope for their recovery.
Patient, physcian
Vary depending on the state
Informed Consent
Informing the patient of treatment options. They need to sign informing that they are are aware of what is going to be done for treatment.
Physician. Patient.
Not stated in text but for every procedure or treatment
Patient Property Form
Records items that patients bring with them into the hospital to ensure they receive everything back.
Hospital staff member and patient
(Not stated in the text, but probably at the time property is taken from the patient)
Discharge Summary
Document stating what patient was treated for what procedures were performed, treatment and condition @ discharge and information provided to the patient and family. physician Right after release
History and Physical Examination
The patient’s chief complaint, present illness history, past history, family history, social history, current medications, and review of systems
Staff member who directly obtained this information from the patient
Variable between JCAHO and AOA, but usually not more than 7 days before or 48 hours after admission
Consultation Reports
Consultant’s opinion and findings based on a physical
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 Report
Brief Description of Contents
Who Signs the Report
Filing Standard
Face Sheet
Patient identification, financial data, clinical information (admitting and final diagnoses)
Attending physician
30 days following patient discharge
Advanced Directives
Patients over the age of 18 have the right to provide instructions on how they want to be treated in case they get very sick and there is no hope for their recovery.
Patient, physcian
Vary depending on the state
Informed Consent
Informing the patient of treatment options. They need to sign informing that they are are aware of what is going to be done for treatment.
Physician. Patient.
Not stated in text but for every procedure or treatment
Patient Property Form
Records items that patients bring with them into the hospital to ensure they receive everything back.
Hospital staff member and patient
(Not stated in the text, but probably at the time property is taken from the patient)
Discharge Summary
Document stating what patient was treated for what procedures were performed, treatment and condition @ discharge and information provided to the patient and family. physician Right after release
History and Physical Examination
The patient’s chief complaint, present illness history, past history, family history, social history, current medications, and review of systems
Staff member who directly obtained this information from the patient
Variable between JCAHO and AOA, but usually not more than 7 days before or 48 hours after admission
Consultation Reports
Consultant’s opinion and findings based on a physical