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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 patients record. Four of the reports have
been done for you.
Name of
Report
Face Sheet

Brief Description of Contents

Who Signs the


Report
Attending
physician

Filing Standard

Advanced
Directives

Document that the patient has


been notified of his or her right to
have an advance directive.
The patient record must
document whether the
individual has executed an
advance directive
Health care proxy, living will,
medical power of attorney
An explanation
of the risks and benefits of a
treatment or procedure,
alternatives to the treatment or
procedure, and
evidence that the patient or
appropriate legal surrogate
understands and consents to
undergo the treatment
or procedure.

Patient
Medical Center
Representative

Upon admission
Before need of
medical care.

Patient
Attending
Physician

Before surgery
and procedures

Patient
Property
Form

Facility is responsible for listed


items stored in safe, nothing that
is kept in room.

Patient
Witness
Person accepting
property

(Not stated in the


text, but probably
at the time
property is taken
from the patient)

Discharge
Summary

Documents the patients


hospitalization, including
reason(s) for hospitalization;

Attending
Physician

Within thirty days


of discharge

Informed
Consent

Patient identification, financial


data, clinical information
(admitting and final diagnoses)

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

Consultation Consultants opinion and


Reports
findings based on a physical
examination and review
of patient records

Attending
Physician
Consulting
Physician

Physician
Orders

Attending
Physician

(Not stated in the


text, but probably
when
consultation is
requested)
Within a
time frame
specified by the
facility (based on
state laws,
if applicable).

Progress
Notes

Anesthesia

Direct the diagnostic and


therapeutic
patient care activities
Each medication ordered be
supported
by a documented diagnosis,
condition, or indicationforuse.
Notes about ongoing care:
changes in the patient,
complications, consultations, and
treatment
complete documentation of the

Staff who see the


patient sign and
attending
physician
countersigns

At the time they


occur

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

A.History, physical exam, lab and


X-ray exams, and preoperative
diagnosis
B.Therapeutic procedures
C.Postoperative evaluation

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

blood and blood products, any


unusual events or
complications, including blood
transfusion reactions,
and the management of those
events
Written order releasing patient
from recovery room
Ancillary
Testing
Reports

Reports of pathology and clinical


laboratory examinations,
radiology and nuclear
medicine examinations or
treatment, anesthesia
records, and any other diagnostic
or therapeutic
procedures.

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