Medical Documentation/Records OUTPATIENT MEDICAL RECORD

Transcription

1 OPERATING PROCEDURE No Florida State Hospital Chattahoochee, Florida November 19, 2008 Medical Documentation/Records OUTPATIENT MEDICAL RECORD 1. Purpose: To maintain an Outpatient Medical Record, Florida State Hospital Form 548, for each patient receiving outpatient procedures/treatment (i.e., cystos, etc.). 2. Scope: An Outpatient Medical Record Form shall be completed for each patient receiving outpatient procedures/treatment. The original form will be filed in the Outpatient Clinic record and a copy will accompany the patient back to his/her home unit. 3. Training Requirements: Physicians, nurses, and Health Information Services staff will be trained on this operating procedure upon hire into the position during Worksite Education and by their supervisor each time the operating procedure is revised. 4. Procedure: a. The Outpatient Medical Record Form must be written only in black or blue ink. b. The Home Unit Physician will complete the Physical Examination and History sections of the form within hours prior to scheduled outpatient procedure. The form is then taken to the Emergency Room to the attention of the Emergency Room Registered Nurse Specialist Coordinator/Designee. c. Unit 31 outpatient/inpatient services nursing personnel will complete the remainder of the form, which will remain with the patient until he/she is returned to the Home Unit. d. When the patient is ready to be returned to the Home Unit, the Health Information Services personnel will copy the Outpatient Medical Record Form and send the copy with the patient to the Home Unit, where it will be filed in the Data Base Section of the ward chart, directly above the corresponding Minor Operation Record. The original will be filed in the Unit 31 Outpatient Clinic Medical Record. e. If the patient is admitted to Unit 31 Inpatient Services, the Outpatient Medical Record Form is copied at time of transfer and a copy returned to the Home Unit. The original will be placed above the Minor Operative Record in the Unit 31 master record and ward chart. (Signed original on file in Central Health Information Services) DIANE R. JAMES 1 Attachment Hospital Administrator Outpatient Medical Record (FSH Form 548) This Operating Procedure supersedes: Operating Procedure , dated October 30, 2006 Office of Primary Responsibility: Health Care Medical Service Director Distribution: Florida State Hospital Computer Network Users

2 Operating Procedure November 19, 2008 SUMMARY OF REVISED, ADDED, OR DELETED MATERIAL This procedure was revised to spell out abbreviations. 2

3 PHYSICAL EXAMINATION Date Hour Ht. Wt. Temp. Pulse Resp. B/P General Appearance Does person communicate? Head/EENT Heart (murmur present or enlargement) Date of last EKG and results Lungs Date of last check x-ray and results Abdomen Distention? Spleen enlarged? Liver enlarged? Adenopathy--Neck Axilla Groin Genitalia Extremities--Bones and Joints Present Medications Allergies Diagnosis Is person suitable for outpatient procedure? HISTORY Present Complaint History of Present Illness History of Past Illness Date, M.D. Attending Physician REPORT OF PROCEDURE Informed Consent received? Preoperative Diagnosis Postoperative Diagnosis Procedure Indications for Procedure Surgeon Assistant Medication and Dosage Condition during procedure Time Time Procedure: Date Began Ended Immediate postoperative condition Hemorrhage, Shock, etc. Findings Recommendations INSTRUCTIONS: The Home Unit physician will complete the Physical Examination and History within hours prior to outpatient procedure, then route form to the Emergency Room--to the attention of the Emergency Room Registered Nurse Specialist Coordinator/Designee. Unit 31 Outpatient Services will complete the remainder of the form. To be filed in the Data Base section of the ward chart directly above the corresponding Minor Operation Record. DISTRIBUTION: Original--Outpatient Clinic Record Copy--Home Unit Ward Chart Date, R.N. Signature ADDRESSOGRAPH: *** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY *** FLORIDA STATE HOSPITAL, CHATTAHOOCHEE, FL Form 548, (Revised) Dec 98 FLORIDA STATE HOSPITAL OUTPATIENT MEDICAL RECORD Office of Primary Responsibility: Unit 31 Attachment Page 1 of 2 Page 1 of 2 Operating Procedure

4 RESIDENT S NAME & NUMBER: DATE AND TIME PHYSICIAN S ORDERS/DISCHARGE ORDER NURSE S SIGNATURE, DATE AND TIME For Medicare Residents: The above ordered laboratory tests are medically reasonable and necessary. PHYSICIAN S SIGNATURE & ID #: DATE: Final Diagnosis Date Time Signature/Attending Physician, M.D. DATE AND TIME DISCIPLINE PROGRESS NOTES *** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY *** FLORIDA STATE HOSPITAL, CHATTAHOOCHEE, FL Form 548, (Revised) Dec 98 FLORIDA STATE HOSPITAL OUTPATIENT MEDICAL RECORD Office of Primary Responsibility: Unit 31 Attachment Page 2 of 2

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