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					DOCUMENTATION CHECK
    LIST FOR 4B
ADMISSION DOCUMENTATION
 HISTORY AND PHYSICAL
 SENIOR ADMISSION NOTE
 CARE PLAN
 EDUCATION (write “see edu in HPI” and then
  remember to fill edu field in HPI note)
 24 HR DISCHARGE NOTICE
 PT. SAFETY CARDS
 RECONCILE MEDICATION AND PROBLEM
  LIST
PROGRESS NOTE DOCUMENTATION



DAILY PROGRESS NOTE

EDUCATION FIELD WITHIN THE
 PROGRESS NOTE TEMPLATE
PROCEDURE DOCUMENTATION

 CONSENT: RISKS, BENEFITS,
  ALTERNATIVES, RISKS AND BENEFITS OF
  ALTERNATIVES, DATED, TIMED, SIGNED BY
  PHYSICIAN(only PGY-2/3), WITNESS,
  PARENT
 TIME OUT SHEET
 PROCEDURE NOTE
 LABEL SAMPLES BY PATIENT’S SIDE
 ADEQUATE ISOLATION PRECAUTIONS
  WHILE PERFORMING PROCEDURE
DISCHARGE DOCUMENTATION

   DISCHARGE SUMMARY
   DISCHARGE EDUCATION
   VNS
   ASTHMA ACTION PLAN
   PRESCRIPTIONS
   DISCHARGE ORDER
   SCHOOL/WORK NOTE
   MEDICATION RECONCILIATION
   PROBLEM LIST RECONCILIATION
   SCHOOL EDUCATION FORM (where applicable)

				
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posted:3/1/2012
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