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DOCUMENTATION CHECK LIST FOR 4B

Published byYanti Veronika Kusnadi Modified over 5 years ago

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Presentation on theme: "DOCUMENTATION CHECK LIST FOR 4B"— Presentation transcript:

1 DOCUMENTATION CHECK LIST FOR 4B

2 ADMISSION DOCUMENTATION
HISTORY AND PHYSICAL SENIOR ADMISSION NOTE CARE PLAN EDUCATION (write “see edu in HPI” and then remember to fill edu field in HPI note) 24 HR DISCHARGE NOTICE PT. SAFETY CARDS RECONCILE MEDICATION AND PROBLEM LIST

3 PROGRESS NOTE DOCUMENTATION
DAILY PROGRESS NOTE EDUCATION FIELD WITHIN THE PROGRESS NOTE TEMPLATE

4 PROCEDURE DOCUMENTATION
CONSENT: RISKS, BENEFITS, ALTERNATIVES, RISKS AND BENEFITS OF ALTERNATIVES, DATED, TIMED, SIGNED BY PHYSICIAN(only PGY-2/3), WITNESS, PARENT TIME OUT SHEET PROCEDURE NOTE LABEL SAMPLES BY PATIENT’S SIDE ADEQUATE ISOLATION PRECAUTIONS WHILE PERFORMING PROCEDURE

5 DISCHARGE DOCUMENTATION
DISCHARGE SUMMARY DISCHARGE EDUCATION VNS ASTHMA ACTION PLAN PRESCRIPTIONS DISCHARGE ORDER SCHOOL/WORK NOTE MEDICATION RECONCILIATION PROBLEM LIST RECONCILIATION SCHOOL EDUCATION FORM (where applicable)

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