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Axia College Material

Appendix C

Acute Care Patient Reports

Fill in the following table with a general description 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 patient’s record. Four of the reports have been done 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 | Healthcare proxy, living will, medical power of attorney ( a legal document in which patients provide instructions as to how they want to be treated in the event they become ill and there is no reasonable hope for recovery | Patient | Immediately after signed by patient, during admission |

Informed Consent | Inform patient of procedure and treatments | Physician Informant & Patient | Before procedures are performed |

Patient Property Form | Records items that patients bring with them to the hospital | Hospital staff member and patient | (Not stated in the text, but probably at the time property is taken from the patient) |

Discharge Summary | Outcome of hospitalization, disposition of the case, and follow-up provisions | Attending physician | Within 30 days of discharge |

History and Physical Examination | The patient’s 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 | The provision of health care services by a consulting physician whose opinion or advice is requested by another physician , | Physician or physician staff | Must be received by a...