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 patients record. Four of the reports have
been done for you.
Name of
Report
Face Sheet
Filing Standard
Advanced
Directives
Patient
Medical Center
Representative
Upon admission
Before need of
medical care.
Patient
Attending
Physician
Before surgery
and procedures
Patient
Property
Form
Patient
Witness
Person accepting
property
Discharge
Summary
Attending
Physician
Informed
Consent
30 days following
patient discharge
HCR 210
procedures performed;
care, treatment, and services
provided; patient's condition
at discharge; and information
provided to the
patient and family. The discharge
summary must
fully and accurately describe the
patients condition
at the time of discharge, patient
education when
applicable, including instructions
for self-care, and
that the patient/responsible party
demonstrated an
understanding of the self-care
regimen
History and The patients chief complaint,
Physical
present illness history, past
Examination 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
Attending
Physician
Consulting
Physician
Physician
Orders
Attending
Physician
Progress
Notes
Anesthesia
Anesthesiologist
Medicare CoP
HCR 210
Record
administration of preoperative
medications, anesthetic agents
administered
during operative procedures,
evaluation of the patient
pre- and postoperatively, and
recovery of the patient
from anesthesia during the
immediate postoperative
period.
require
documentation
of a
preanesthesia
evaluation note
by an individual
qualified to
administer
anesthesia within
48 hours
prior to surgery.
Medicare CoP
also require that
an intra operative
anesthesia
record be
maintained.
Operative
Report
Surgeon or
attending
physician
Pathology
Report
Date of examination
Clinical diagnosis
Tissue examined
Pathologic diagnosis
Macroscopic (or gross)
examination
Microscopic examination
Authentication by pathologist
Record of postoperative vital
signs and level of
consciousness, medications
(including intravenous
fluids) and blood and blood
components administered,
I.V. fluids and drugs administered
including
Pathologist
Recovery
Room
Record
A postanesthesia
evaluation
No later than 48
hours after
surgery
A. Prior to
surgery
B. Immediately
after surgery
C. 24 hours
after surgery
As soon as
completed,
usually within 24
hours
Dated, timed,
Upon discharge
and
from recovery
authenticated by room
the responsible
physician
(anesthesiologist)
or certified
registered nurse
HCR 210
anesthetist
Authenticated by
physician
responsible for
release
Laboratory
technician.
Radiologist.
Physician
As soon as an
interpretation has
been made
(usually within 24
hours).
Whomever did
test or procedure
HCR 210