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MEMO -Accomplishing Record - Chart RESPONSIBILITIES 2008 .doc Size : 0.045 Kb Type : doc |
MEMORANDUM
TO: ALL DEPT. HEADS / CHIEF RESIDENTS / SECTION CHIEFS
FR: OFFICE OF CHIEF TRAINING OFFICER
RE: CHART RESPONSIBILITIES
DATE: July 23, 2008
Attached are the CHART GUIDELINES prepared and approved by the undersigned for purpose of proper preservation of charts. This is of utmost importance for the Annual Census, Legal use, Research and Compliance to the LGU and DOH requirements.
Kindly disseminate these guidelines to all concerned and be guided accordingly.
PECOS R.I. CAMARINES, MD, MHA TERESITA J. DIMAYACYAC, RN, MAN
Chief Training Officer Chief Nurse
EDGAR ALLAN SANTOS EMILIO PASTRANA
Head, Records Section Head, Admitting Section
Noted by:
ZALDY R. CARPESO, MD
Hospital Director
GENERAL GUIDELINES
- NO CHART shall be HAND CARRIED by patient. Only the following are authorized to bring the chart from one area to another.
- Doctor
- Nurse
- Nursing Aide
- Nursing Student
- Admitting Clerk
- Records Section Clerk
- Complete Discharged Charts must be received by the Records Section within three (3) days after discharged.
- DOCTORS MUST NOT GET DISCHARGED CHARTS FROM THE NURSE STATION. If badly needed, the discharged chart must be hand carried by the Section Nurse to the Admitting Section for recording, then to the Records Section. The Doctor may then borrow the chart from the Records Section.
ALL CHARTS MUST BE BORROWED FROM THE RECORD SECTION – properly signed out and countersigned by the Records Section Clerk, including the date and time.
All borrowed charts must be returned by the borrower to the Records Section, properly accepted and checked by the Record Section Clerk.
CHART RESPONSIBILITIES
DOCTORS:
- must complete the following:
1. Front Page – (Admission and Discharge Record)
a. Date and Time of discharge
b. No. of Days of Stay
c. Attending Physician/s
d. Admitting Diagnosis
e. Final Diagnosis (DO NOT WRITE “THE SAME”)
f. Signature over Printed Name and date
2. History Form – All admissions must have complete history and admitting diagnosis. History Form may differ from one Dept. to another.
3. Post-Operative Cases – Complete the following:
a. Operation Record (to be completed by Surgeon)
b. Technique of Operation (to be completed by Surgeon)
c. Anesthesia Records (to be completed by Anesthesiologist)
4. Discharge Summary / Abstract – Different Dept. may have specific forms. Don’t forget your signature over printed name. Complete all informations
NURSES:
- must review the chart’s completeness and request the doctors to complete lacking informations needed from them.
- log all complete Discharged Charts at the DISCHARGE LOG BOOK in the station.
- submit all complete and logged Discharged Charts to the admitting section (the following day). Admitting clerk must countersign accepted charts and write the date and time.
ADMITTING SECTION:
- Must received complete discharged charts from the different Nursing Stations and countersign Discharge log book including the date and time.
- Record Discharged Charts at the Admitting Section Discharged log book and afterwards, forward all charts to the Records Section on or before 4:00 PM (same day).
- Have the Admitting Section Discharged log book countersigned by the receiving Records Section Clerk and write the date.
CHART FLOW
- DISCHARGED PATIENTS:
Completion of chart by the Discharging Doctor (8am – 5pm)
To be checked by Station Nurse
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To Admitting Section
(8:00am – 10:00am the following day)
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To Records Section
(up to 4:00pm same day)
- OPD CHARTS
OPD charts to be released and carried by
OPD clerk to the Corresponding OPD Rooms
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To be received by Nurse / Nursing Aide for
Chronological filing on a “FIRST IN, FIRST OUT Scheme”
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After examination of patient,
Recording at the OPD log book (by the Nurse)
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Return to OPD station after the OPD (same day) and
To be received by the OPD Clerk
“EMERGENCY”
- ISSUANCE OF A MEDICAL CERTIFICATE (at OPD and ER)
OPD / ER RECORD
(with Complete Diagnosis)
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To Admitting Section
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To Records Section
To OPD / ER