Acute Care Patient Reports

Acute Care Patient Reports

Fill in the missing content in the table below. Insert general descriptions of each type of patient report, who may have to sign or authenticate it, and the standard

time frame that JCAHO or AOA requires for it to be completed or placed in the patients record. Four of the reports have already been filled in for you.

Name of Report
Brief Description of Contents
Who Signs the Report
Filing Standard
Face Sheet

Patient identification, financial data, clinical information (admitting and final diagnoses)
Attending physician
30 days following patient discharge
Advanced Directives

Informed Consent

Patient Property Form

(Not stated in the text, but probably at the time property is taken from the patient)
Discharge Summary

History and Physical Examination
The patients chief complaint, present illness history, past history, family history, social history, current medications, and review of systems
Staff member who directly obtained this information from the patient
Variable between JCAHO and AOA, but usually not more than 7 days before or 48 hours after admission
Consultation Reports

Physician Orders

Progress Notes
Notes about ongoing care: changes in the patient, complications, consultations, and treatment
Staff who see the patient sign and attending physician countersigns
At the time they occur
Anesthesia Record

Operative Report

A. History, physical exam, lab and X-ray exams, and preoperative diagnosis
B. Therapeutic procedures
C. Postoperative evaluation
Surgeon or attending physician
A. Prior to surgery
B. Immediately after surgery
C. 24 hours after surgery
Pathology Report

Recovery Room Record

Ancillary Testing Reports