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Psychiatric Chart Review Form

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Psychiatric Chart Review Form Powered By Docstoc
					HOSPICE Chart Review Data Collection Tool
Date:___________ #______                  _

Pt. ID #                                      Site Code:________

1. AGE:               Stage of Illness:
2. Sex: 1 – Male 2- Female 3-Transgender
3. Admission Date:___________
4. Discharge Date (other than death):______________    Date of Death:_____________
5. Medical record contains patient acknowledgement of receipt of Resident’s Rights (on Informed
Consent):
                            Y-Yes, pt/rep signed N-No, not found
6. Medical record contains patient acknowledgement of receipt of “Guidelines for Residence”
regulations including agency’s client appeals / grievance procedures on that form:
                            Y-Yes, pt/rep signed      N-No, not found
7. Medical record contains patient signature giving “Informed Consent for Resident Participation”:
                            Y-Yes, pt/rep signed      N-No, not found
8. Medical record contains patient signature giving most recent “Consent for Release of
Confidential Information”:
                            Y-Yes, pt/rep signed      N-No, not found
9.   The Admission Orientation Checklist as found on the “Admission Info/Resident Information” is:
                       Y-Yes, complete                 N-No, not complete
10. The medical record contains Admission Orders:
                                  Y-Yes          N-No, not found
11. The medical record contains Symptom Management (S/M) Orders:
                                  Y-Yes         N-No, not found
12. The medical record contains Additional Resident-Specific Orders:
                                  Y-Yes          N-No, not found
13. The medical record contains “Medication Administration Record”
                                  Y-Yes          N-No, not found
14. “Medication Administration Record”of PRN MEDS includes for ALL meds listed:
                                  Y-Yes          N-No, not found
15. The Personal Effects Inventory is completed within 72 hrs of admission:
                                  Y-Yes          N-No, not found
Hospice Chart Review Data Collection Tool (continued)

16. The medical record contains the completed initial Plan of Care:
                                   Y-Yes          N-No, not found
17. Weekly IDT Care Plan Update was attended minimally/most recent by within yr:
                          Y-Yes            N-No, not found              NA -
18. “Resident Register/Demographics” form states client is homeless:
                                  Y-Yes, homeless       N-No, not homeless
19. Nursing Assessment & Psychosocial Assessment forms state client has active substance abuse
   (SA):
                               Y-Yes, active SA           N-No active SA
20.      Nursing Assessment & Psychosocial Assessment forms states client has active psychiatric
      illness (MI):
         Y-Yes, active psychiatric illness             N-No active psychiatric
21. “Resident Register/Demographics” form states client’s AIDS status as:
                  Y-Yes, AIDS status documented          N-No AIDS status not           NA-
22.    “Resident Register/Demographics” form states:
         Year of HIV Diagnosis:____________Year of AIDS Diagnosis:___________
                                        NA-Not Documented
23.     “Resident Register/Demo” form states Bereavement card sent & date:
 Y-Yes, documents date Bereavement Card sent N-No documentation that Bereavement
                        Card was sent NA-NA, pt not deceased
24. Each Skilled Nursing entry is properly documented
                                         Y-Yes          N-No
25.    Documentation of care rendered by SN includes pt response:
                       Y-Yes N-No S-Sometimes, but not in every instance
26. “Nursing Assessment” is completed:
                                         Y-Yes          N-No
27. “Psychosocial Assessment” is completed:
                                         Y-Yes          N-No
Hospice Chart Review Data Collection Tool (continued)

28. The medical record includes evidence and documentation of “bereavement services”:
               Y-Yes           N-No              NA-NA, pt not deceased or no family
29. The medical record includes evidence and documentation of “support services to the family”:
               Y-Yes           N-No              NA-NA, pt not deceased or no family
30. The medical record contains a completed Death Notification Form:
                       Y-Yes           N-No           NA-NA, pt not deceased
31. The medical record contains a completed Coroners Information Sheet:
                       Y-Yes           N-No           NA-NA, pt not deceased
32. Physician is notified of patient’s death :
                       Y-Yes           N-No           NA-NA, pt not deceased
33. Total # of days of care in facility within year:__________

				
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Description: Psychiatric Chart Review Form document sample