Health Information

YES

NO

N/A

Discharge summary/clinical resume dictated within 48 hours of discharge

Discharge summary includes reason for hospitalization

Discharge summary includes significant findings

Discharge summary includes procedures and care provided

Discharge summary includes patient’s condition at discharge

Discharge summary includes instructions to patient and family, if applicable

Completion of H&P and/or admitting note w/in 24 hours of admission

Allergies to foods and medicine documented

Reason for admission for care, treatment or services documented

Progress notes dated and signed

Progress notes timed

Progress notes written every day by attending or consulting physician

Progress notes legible

Method of signature/authentication: written, electronic, computer key

Orders dated and signed

Orders timed

Orders legible

Each verbal order is dated and identifies the names of the individuals who gave and received it and the record indicates who implemented it

DO NOT USE abbreviations present?

Pre-, intra-, and post-anesthesia information documented by responsible individual

Informed consent signed and dated by patient

Operative report dictated/written on day of surgery

Operative report contains pre- and post-op diagnosis

Operative report indicates specimen(s) removed, if applicable

Operative report indicates estimated blood loss

Pathology report present, if applicable