Question

The acute care facility inpatient record contains numerous reports that are documented by various facility personnel and medical staff providers. Each facility establishes a filing order for inpatient and discharged patient reports to ensure that information can be easily located in the record. This assignment will familiarize you with the content of an inpatient record and the typical order of reports filed in a discharged patient record.

Instructions:

1. the chart below contains a list of acute care discharged patient reports.

2. reorder the reports (1-15) according to the way they should be filed in a discharged patient record (to get you started, numbers 1 and 15 have been entered.)

3. Post your reordered results on the discussion board and review the posts of your classmates. Reply to the post of one of your classmates, following netiquette rules. Make sure you are specific in your responses, and that you do not just rewrite what someone else has posted.

Sequence Reports

  Advanced Directives

Anesthesia record

Ancillary testing reports

Consent to admission

Consultation reports

Discharge summary

1 Face sheet

History and physical examination

Nursing section

Operative report

Pathology report

15 Patient Property form

Physician orders

Physician progress notes

Recovery room record

Answer 1

Discharged patient records are typically organized according to chronological date with the oldest data filed first in a

1. Face sheet.

It is the first sheet in a paper record. Usually, demographic data, physicians record and discharge diagnoses and procedures are mainly mentioned in the face sheet.

2. Consent to admission

3. History and physical examination

4. Consultation reports

5. Discharge summary

6. Anesthesia record

7.Physician orders

8. Physician progress notes

9.Operation notes

10. Recovery room record

11. Nursing section

12. Ancillary testing reports

13. Pathological reports

14. Advanced directives

15. Patient property form