DOCUMENTATION CHECK LIST FOR 4B

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Presentation transcript:

DOCUMENTATION CHECK LIST FOR 4B

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

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

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

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)