MEMO

Memorandum

Memorandum

MEMORANDUM FOR RECORD

SUBJECT: Patient Backlog of Incomplete Medical Record

PURPOSE:

I. ADMISSION

To recognise and get admission facts and numbers in a concise, methodical manner.

To assemble admission facts and numbers on the patient's problems/needs on admission, encompassing the identification of desires pertinent to release designing for that persevering and formulation of a nursing design of care founded on those needs.

To record disposition of the patient's property.

 

II. DISCHARGE

To supply concise and methodical documentation of the patient's rank at the time of release encompassing release position, mental rank, persevering status and a present evaluation founded on persevering conclusion standards.

To supply a abstract of medication/treatment data on the Discharge Instructions. Exception: All data considering a detainee will be granted to the guard.

(For added data, mention to Hospital Policy: 2.20, Prisoner - Patient.)

To supply documentation of an interhospital or interagency transfer.

 

III. DEATH

To supply for documentation of data upon the death of a patient.

The next parts are about Upon Admission, Upon Discharge, and Upon Death.

 

I. UPON ADMISSION

A. Completion and Signature of Form

The RN, RN Applicant, or LPN will entire the Patient History and Discharge Record (S/N 1048) inside (8) hours of the patient's admission, despite of imminent move to another unit. The permitted doctor will signal the time when the pattern is completed. If the LPN finishes the pattern, the RN should consider the facts and numbers assembled and signal on the signature line.

 

B. Utilizing the Form

The Patient History and Discharge Record will be accomplished for all inpatient admissions except for those flats who utilize accepted unit exact admission/discharge forms.

In supplement, Neonatal Intensive Care and Newborn Nursery will utilize the mother's admission form.

The Day Surgery Assessment (SN 1414) is accomplished for patients accepted to Day Surgery. This evaluation may be accomplished inside 30 days before surgery.

Changes to the patient's status will be revised former to surgery/procedures.

The unit ...