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MMC Medical Records Checklist

This document contains a checklist of items that should be included in a patient's medical records at admission and discharge. The checklist includes sections for demographic information, admission and discharge details, physical exam records, lab results, doctor's orders, progress notes, discharge summary, temperature/pulse/respiration records, intravenous records, medication records, and nurses' notes. The document emphasizes correctly and completely filling out each item without erasures by lining out incorrect entries and writing the correct entry above with a signature.

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Eduardo Anerdez
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225 views2 pages

MMC Medical Records Checklist

This document contains a checklist of items that should be included in a patient's medical records at admission and discharge. The checklist includes sections for demographic information, admission and discharge details, physical exam records, lab results, doctor's orders, progress notes, discharge summary, temperature/pulse/respiration records, intravenous records, medication records, and nurses' notes. The document emphasizes correctly and completely filling out each item without erasures by lining out incorrect entries and writing the correct entry above with a signature.

Uploaded by

Eduardo Anerdez
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
  • MMC Medical Records Checklist
  • Continued: MMC Medical Records Checklist

MMC MEDICAL RECORDS CHECKLIST

ADMISSION AND DISCHARGE RECORD [


]
Patients name [ ] MR#[ ] Address [
]
Demographic data: complete [ ]
incomplete [ ]
D. admission [ ] D. discharge [ ]
Admitting officer [ ] Admitted DX [ ]
Final DX [ ]
ICD Code [ ] Disposition [ ]
P.E Record [ ]
History of present illness [ ] General
survey [ ]
V/S [
] Personal History [
] Past
Medical History [ ]
Review of systems [ ] Family history [
]
Consent Form [ ]
Signed Consent to Care [
]
Date
Signed [ ]
DAMA [ ] Signed Acknowledgement of
Responsibility [ ] Date [ ]
Laboratory Results [ ]
Complete [ ] Incomplete [ ]
Doctors Orders Sheet [ ]
Date [ ] Time [ ] Doctors Signature [
]
Date & Time noted [ ] R.N Signature [
]
Progress Notes [ ]
Date [ ] Time [ ] Doctors Signature [
]
Discharge summary [ ]
Date Admitted [ ] Date Discharge [ ]
Attending Physician [ ]Admitting DX [
] Final DX [ ] C/C [ ] Brief Clinical
History &Pertinent P.E [ ]
Lab. Findings [ ] Course in the Ward [
]
Disposition [ ] Date Accomplished [ ]
R.O.D sign [ ]
TPR Sheet [ ]
Date [ ] NHD [ ] complete TPR graph [
] B.P [ ]
Wt. [ ]Urine [ ] Stool [ ] NOD sign [
]
Intravenous Sheet [ ]
Date [ ] Bot.# [ ] Kind of Soln. [ ]
Drop/ Drip Factor [ ]Time Started [ ]
Volume [ ] Nurse Sig. [ ]
Medication Sheet [ ]
Date [ ] NHD [ ] Medications : Generic
Name [ ]
Brand Name [ ] Frequency [ ] Dose
[ ]
Time Element [ ] NOD sign [ ]
Nurses Notes [ ]
Date [ ] Shift [ ] Time [ ] Diet [ ]
NOD sign [ ]
M.R. Checklist Date Accomplished:
______________
Signature of Personnel In-charge:
_______________

Note: Each page of the Medical Record must


have complete patients name, date admitted,
sex, and age. All spaces must be filled up
correctly. No erasures please. But if you made a
wrong entry do not use correction fluid to erase
it rather make a single line over the wrong entry,
write the correct entry above it and sign.
Thank you. The MR Management.

MMC MEDICAL RECORDS CHECKLIST

ADMISSION AND DISCHARGE RECORD [


]
Patients name [ ] MR#[ ] Address [
]
Demographic data: complete [ ]
incomplete [ ]
D. admission [ ] D. discharge [ ]
Admitting officer [ ] Admitted DX [ ]
Final DX [ ]
ICD Code [ ] Disposition [ ]
P.E Record [ ]
History of present illness [ ] General
survey [ ]
V/S [
] Personal History [
] Past
Medical History [ ]
Review of systems [ ] Family history [
]
Consent Form [ ]
Signed Consent to Care [
]
Date
Signed [ ]
DAMA [ ] Signed Acknowledgement of
Responsibility [ ] Date [ ]
Laboratory Results [ ]
Complete [ ] Incomplete [ ]
Doctors Orders Sheet [ ]
Date [ ] Time [ ] Doctors Signature [
]
Date & Time noted [ ] R.N Signature [
]
Progress Notes [ ]
Date [ ] Time [ ] Doctors Signature [
]
Discharge summary [ ]
Date Admitted [ ] Date Discharge [ ]
Attending Physician [ ]Admitting DX [
] Final DX [ ] C/ [ ] Brief Clinical
History &Pertinent P.E [ ] Lab.
Findings [ ] Course in the Ward [ ]
Disposition [ ] Date Accomplished [ ]
R.O.D sign [ ]
TPR Sheet [ ]
Date [ ] NHD [ ] complete TPR graph [
] B.P [ ]
Wt. [ ]Urine [ ] Stool [ ] NOD sign
[ ]
Intravenous Sheet [ ]
Date [ ] Bot.# [ ] Kind of Soln. [ ]
Drop/ Drip Factor [ ]Time Started [ ]
Volume [ ] Nurse Sig. [ ]
Medication Sheet [ ]
Date [ ] NHD [ ] Medications : Generic
Name [ ]
Brand Name [ ] Frequency [ ] Dose
[ ]
Time Element [ ] NOD sign [ ]
Nurses Notes [ ]
Date [ ] Shift [ ] Time [ ] Diet [ ]
NOD sign [ ]
M.R. Checklist Date Accomplished:
______________
Signature of Personnel In-charge:
_______________

Note: Each page of the Medical Record must


have complete patients name, date admitted,
sex, and age. All spaces must be filled up
correctly. No erasures please. But if you made a
wrong entry do not use correction fluid to erase
it rather make a single line over the wrong entry,
write the correct entry above it and sign.
Thank you. The MR Management.

MMC MEDICAL RECORDS CHECKLIST Note: Each page of the Medical Record must have complete patient’s name, date admitted, s
Note: Each page of the Medical Record must have complete patient’s name, date admitted, sex, and age. All spaces must be fi

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