Statement of Patient Leaving Hospital Against Advise Form - DOC by apl62599


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									Health Information Management                                      Date Written: 01/29/96
Record Processing Section                                          Date Revised: 10/16/09

Subject: Filing Order of Medical Record

                                                      7702         Intake Cardiac Rehabilitation
   FILING ORDER OF INPATIENT MEDICAL                               Assessment
                RECORD                                5041         Pediatric Assessment 0-5 years
             (Open Record)                            5042         Pediatric Assessment 6 years to
5001        Record of Sensitivity
5003        Data Sheet                                5170         Initial Nutritional Assessment
5346        Final Discharge Note                      5103         Observation Unit Form

            PHYSICIAN'S ORDERS                        5302         Multidisciplinary Team Treatment
            (Filed in Reverse Chronological                        Plan-Summary Sheet
Order)                                                5303         Multidisciplinary Treatment Plan
5350/*POECode Status/Treatment Support Level          5303 A       Multidisciplinary Discharge Plan
Order                                                 7024         Breast Patient Evaluation
5350/POE Physician's Order Sheet                      5107         Antepartum Record
5350      Physician's Order Sheet                     5120         Dubowitz Exam
          (departmental)                                           Ballard Score
5350      A57 Chemotherapeutic Agents                 5300 G       Progress Note Newborn Data Record
          Physician’s Order Sheet                                  Birth Certificate
5350 A52  Physicians Order Sheet                      5018         Perinatal Profile
          Neonatal/Pediatric Parenteral               6001         DSU Questionnaire
          Nutrition                                   1048         Prenatal Self-Assessment
          Discharge Prescription Form                 5020         ESRD Patient’s Long Term Program
5630      Patient Care Plan (Adult)                   5116         Outpatient Screening
5646      Multidisciplinary Patient Care Plan         7047         Colposcopic Examination Record
5646 A    Multidisciplinary Patient Care Plan         2013         Neuro Exam (if answer to consult file
          Summary                                                  under Consults)
5649 A-Z  Plan of Care (Protocol - by date)           7003A-D     Ophthalmology Examination
                                                      2031         Ophthalmology Sheet (Pleoptic-
            ADMISSION                                              Orthoptic Sheet)
            (Filed in Chronological Order)                         Tangent Filed Sheet (attached to
7005        ER Record (if Received with the                        above form)
            Admission)                                5080         Retinal Drawing Chart
5060        Referral Tracking Encounter-
5061        Referral Tracking Encounter-History I
            Women's Hospital Rooming In Policy

            (Filed in Chronological Order)
            OB/Gyn Screen/Health History
5100        A-G          History and Physical
            Exam (Yellow Border)
5180        Initial Patient Evaluation
5181        Subsequent Encounter

            HISTORY/PHYSICAL (cont.)
5105        Burn Diagram
7031A       Conscious Sedation
                                                                   **SURGICAL RECORDS
D:\Docstoc\Working\pdf\1a69aa10-271b-47ed-922f-f7590cce19a6.doc      Health Information Management
Department x29266                     1
Health Information Management                                     Date Written: 01/29/96
Record Processing Section                                         Date Revised: 10/16/09

Subject: Filing Order of Medical Record

            (Filed in Chronological Order)            5346-102    4 Hour Request for Release
6012        Bone Marrow Interpretation                            Procedure Notes (printed from
2207        Coronary Artery Bypass Graft Graph                    ClinWeb)
6021        Cardio/Thoracic Sheets                                PROGRESS NOTES (cont.)
            (Extracorporeal Circulation)              1080        Gynecology Discharge Instructions
6020 B      Day Surgery Unit Patient Care                         Rebecca Sealy
            Record – Perioperative Nursing            3001        Head Injury Precautions
6017        Anesthesia Report                         5349        Cancer Patient Staging Form
6017 A      OB Anesthesia Record                      5125        Patient Health Information
            *Surgical Consent Form (if
            applicable)                                           CONSULTANT REPORTS
6013        Transfusion Record                                    (Filed in Chronological Order)
6016        Anesthesia Pre-Operative Review           5400 A-Z    Request for Consultation and Report
            (Purple Edge)                                         (Departmental)Answer to Consults
6005        Preoperative Checklist                    5403        Social Service Evaluation
1084        Surgical Procedure Record –               5404        Social Work Referrals
            Rebecca Sealy                             7710        Psychosocial Assessment
6015        Perioperative Nursing Assessment          1091        Medication Assistance Screening,
            Typed Operative Report                                Department of Social Services
6025        Otolaryngology Operative Report           Pilot       Spiritual Assessment
5811        Gastroenterology Report- Endoscopy        2013        Neuro Record if Answer to Consult
            Exam                                      5401        Neuropsychology Report (White
5811 A      Gastroenterology Report-                              Sheet)
            Esophageal Manometry Exam                 5402        Galveston Orientation and Amnesia
5811 B      Gastroenterology Report-                              Test
            Laparoscopy Exam                          5201        Gait Training Evaluation
6020        Post Anesthesia Care Unit Record          5419        Wound Care Evaluation - PT
1086        Rebecca Sealy Anesthesia/Nursing          8009        Upper Extremity
            Assessment                                            Evaluation/Treatment
            Endoscopic Report                         5232        Activity of Daily Living- Checklist
5658        Interim Note for TDC Observation          8019        Hand Evaluation/Treatment Plan -
            Patient                                               OT
                                                      2125        Gas Exchange
            PROGRESS NOTES                            5602 A-Z    Allergy Skin Tests
            (Filed in Chronological Order)            1051        Rheumatic Disease Patient
5332 A-Z    Patient Discharge Instruction                         Treatment Record
5333 A      Patient Discharge Instruction – TDCJ      5451        Nerve Conduction Study
            Central Venous Catheter                   5114        Spinal Survey
5092        Interdisciplinary Plan of Care – Day      5432        Electroencephalography Report
            Surgery                                   6006        Anesthesiology Consultation
5093        Interdisciplinary Plan of Care –                      Arrhythmia Report
            Rebecca Sealy                             5460        Arterial Consultation Report- Lower
2001 A      Internal Medicine Clinic Admitting                    Extremities
            Form                                      5461        Cerebral Consultation Report-
            TPN Data Sheet                                        Vascular
5127        Premature Weight Chart                    5462        Venous Consultation Report-Lower
5629        Critical Path (all services)                          Extremities
7703        Interdisciplinary Rehab Flow Sheet        2186        Flow Volume Curve
5308        Neonatal Transport Note                   5476        Exercise Study
5308 A      Neonatal Transport Note
5308 B      Neonatal Transport Note Addendum
            Delivery Note
5300 A-Z    Progress Notes (except 5300 g)
D:\Docstoc\Working\pdf\1a69aa10-271b-47ed-922f-f7590cce19a6.doc     Health Information Management
Department x29266                     2
Health Information Management                                     Date Written: 01/29/96
Record Processing Section                                         Date Revised: 10/16/09

Subject: Filing Order of Medical Record

                                                      5638        Serum Bilirubin
            CONSULTANT REPORTS (cont.)                1055        Pre-Transplant Evaluation Data
2187        Ventilation Studies                                   Summary
7026        Audiology Report - Hearing and
            Evaluation and Special Tests                          LAB (cont.)
7027        Audiology Report- Audiogram and           1056        Pre-transplant Evaluation/Donor
            Impedance                                             Specific Transfusion Protocol
2041        Indirect Mirror Examination               5808        Histocompatibility
5410        Retinopathy Ophthalmic Examination                    Clinical Lab - Cumulative Summary
            (ROP) Record                              2100        Laboratory Reports (orange)
2043        Classification of Laryngeal Cancer        5833        Nuclear Medicine Report
2044        Oral Exam                                 2185        Transportation Immunology Lab
2045        Direct Laryngoscopy                                   Genotype Report
5478        Suspected Transfusion Reaction            2196        Hemodialysis Lab (front)
            Investigation                             2197        Peritoneal Dialysis (back)
            (Post Reaction Test Report)               2198        Pedi Peritoneal Dialysis Log-D.W.
5420        Hyperbaric Chamber Log                                Cycler
            Plan of Care Assessment for               5800        Urine Amino-Acids
            Outpatient Rehab (HCFA 700)               5801        Plasma Amino Acids
            Update Plan of Care/Progress for          5802        Lysosomal Enzymes
            Outpatient Rehab (HCFA 701)               5812        Bone Mineral Analysis
5809        Blood Count and Interpretation            5810        Dermatopathology Laboratory Report
5611 A-Z    Treatment and Activity Record             5820        Rhinotest Mp (computerized)
5444        Nutritional Assessment for Dialysis       5463        Tuberculosis Skin Test
            Patients                                              Other Laboratory Reports
5445        Nutritional Assessment for Transplant
            Patients                                              X-RAY/EKG
5400 E      Request for Consult-Diabetes Self M                   (Filed in Chronological Order)
            anagement Training                        5266        Radiotherapy Form
5448        Endocrine Consult for Diabetes Team       5840        Radiology Report
5470        Coronary Angioplasty Report               5440        Radiology X-Ray Consult Form-
5490        Amniocentesis                                         Cancellation Notice
5491        Biophysical Profile                       5837        Heart Station E.K.G.
5492        Fetal Scalp Sampling                      5841        Exercise Stress Test
5493        Nonstress Test                            5359        Pediatric Echocardiography Report
5494        Oxytocin Challenge Test                   5838        Exercise ECG Data
5495        Real Time Ultrasound Exam                 5839        Echocardiogram- Dopler Service
            Pre-Anesthetic Evaluation                 5446        Intracardiac Electrophysiology study
5104        Documentation of Evaluation and           5449        Signal Average EKG Report
            Management Service -                      2192        Cardiac Catheterization Report
            Cardiothoracic Surgery                    2193        Left Ventriculogram Report (Front)
5411        Request for Consultation and                          Coronary Arteriogram Report (Back)
            Response (also electronic format)                     Evaluation Summary
                                                                  Report/Department of Neurology
            LAB                                                   Electromyogram
            (Filed in Chronological Order)            5450        Electromyography Report
102         Premature Serum Bilirubin
5806        Cytopathology (yellow)                                NURSES NOTES
5807        Immunodiagnostics                                     (Filed in Reverse Chronological
            Cumulative Mycobacteriology Report                    Order)
            Infant Blood Type and Rh                  5649 B      Nursing Orders
5804        Antibiotic Level Interpretive Report      5433        Arrhythmia Report
5804 A      Specials Antibiotic Level Interpretive    5312        Heparin Therapy
D:\Docstoc\Working\pdf\1a69aa10-271b-47ed-922f-f7590cce19a6.doc     Health Information Management
Department x29266                     3
Health Information Management                                     Date Written: 01/29/96
Record Processing Section                                         Date Revised: 10/16/09

Subject: Filing Order of Medical Record

            NURSES NOTES (cont.)                      5664        Interdisciplinary Patient/Family
5626        Neomap                                                Teaching-Neonatal Nurseries
5626 A      Neomap 37 – 40 Weeks                                  Addendum
5128        Circumcision Checklist                    5664 B      Interdisciplinary Patient/Family
5622        Neonatal Nurseries Admission Flow                     Teaching-Neonatal Nurseries
            Sheet                                                 Addendum
1067 A-Z    Nursing ProgressNote/Individualized       5665        Discharge Planning Record
            Patient Care                              5668        Discharge Planning Worksheet
5268        Skin Documentation Record                 5669        Multidisciplinary Discharge Planning
            Pulmonary Support Flow Sheet                          Notes
                                                      5672        Discharge Needs-
            OTHER RECORDS                                         Assessment/Summary
            (Filed in Reverse Chronological           6050        Mental Health Discharge Summary
5601        Adverse Drug Reaction Test                            CONSENT FORMS
1009        Nursing Diagnosis List                                (Filed in Chronological Order)
            ISCU/Newborn Nursery                      6049        Self-Care Instruction Following
5681        Medication Administration Record                      Endoscopic Procedures
1028        Patient Medication Self-                              Patient Discharge Notification
            Administration Record                     5036        Consent for Organ Donation
            Multiple Injection Record                             Inpatient Authorization and Consent
5701        Chemotherapy Checklist                    5028        Consent for Release of Patient
7044        Chemotherapy Administration Note                      Information for Reimbursement
7054        Hemodialysis Flow Sheet                               and Continuity of Care
7055        Hemodialysis          Flow Sheet          5038        Important Message from Medicare
            Addendum                                  5039        Important Message from Medicare-
5641        Peritoneal Dialysis Flow Sheet                        Spanish
5643        Dialysis Log                              5040        Important Message from Champus
5631        Labor and Delivery/Birth Center           5009        Consent for Diagnosis and Treatment
            Nursing Flow Sheet                        5009-101    Refusal to Consent to Treatment
5670        Daily Burn Care                           6000        Disclosure and Consent Medical and
5691        Ultrafilitrate Burn Flowsheet                         Surgical Procedures
                                                                  Agreements, Authorizations, and
            OTHER RECORDS (cont.)                                 Irrevocable Assignments
5661        Seclusion Sheet List Increased            6000 A-Z    Disclosure and Consent
            Observation Checklist                                 (Departmental)
5640        Surgery Intensive Care Units- Data        2001-101    Emergency Services – Agreement &
            Sheet                                                 Authorization
Trial       Resuscitation Flow Sheet                  5011        Consent-Acknowledge-
5635 S      Adult Diabetes Education Flow Sheet                   Hysterectomy
5690        Cardiac Rehabilitation Flow Sheet
2522        Electroshock Therapy                                  CONSENT FORMS (cont.)
5646 A      Multi-Disciplinary Patient Care           6004        Consent for Sterilization
            Conference                                6010        Mental Health Code Informed
            Hospital School Records                               Consent
2500 A      Department of School Services                         Disclosure & Consent for
            Education Notes                                       Electroconvulsive Therapy (ECT)
                                                      6011        Review of Patient's Rights
PATIENT EDUCATION/DISCHARGE PLAN                      5030        Directive to Physician for Persons
          (Filed in Chronological Order)                          Under 18 Years of Age
5635      Interdisciplinary Patient/Family            5013        Consent for Photograph
          Teaching                                    2513        Consent for Investigative Drugs
                                                      5025        Disclosure and Consent for Use of
D:\Docstoc\Working\pdf\1a69aa10-271b-47ed-922f-f7590cce19a6.doc     Health Information Management
Department x29266                     4
Health Information Management                                      Date Written: 01/29/96
Record Processing Section                                          Date Revised: 10/16/09

Subject: Filing Order of Medical Record

5025 A      Documentation of the Need for             6049        Self-Care Instruction Following
            Emergency Administration of                           Endoscopic Procedures
            Neuroleptic Medication without the        5027        Prenatal HIV Testing Consent
            Consent of the Patient                    5908        Consent for determination of
7033        Consent for Release of Information                    Antibody to HIV in the Blood
            Concerning Alcohol or Drug                7601        Emergency Apprehension and
            Dependent Patients Presence In                        Detention-Parts 1-6(filed in date order
            Facility and General Medical                          with Consent Forms)
            Condition                                             ADVANCE DIRECTIVES
7039        Consent for Examination, Treatment,                   (Filed in Chronological Order)
            and Release of Records-                   POA-5029    Medical Power of Attorney
            UTMB MIHIA Program                        5030        Directives to Physicians
2618        Consent for Somatic Therapy                           Out of Hospital DNR
2505        Consent for Physician's Assistant         7079        Acknowledgment of Receipt of Notice
            Trial Consent for Pedi Cardiology                     of Privacy Practice
            Cardiac Catheterization Trial
            Consent for Immunization Series
2515        Statement of patient Leaving Hospital
            Against Medical Advise                    *POE – Physician Order Entry – the electronic
            (front) Leave of Absence Release          orders system
            from Responsibility (back)                **If the patient had surgery, the surgical
            Patient Release Form                      consent form is filed with the surgical records.
            Patient's Bill of Rights (including        The consent is placed behind the Anesthesia
            Rehab version)                            Record, form #6017.
            Consent Use of Emergency Restraint
5014        Delay Discharge of Infant
            Instruction to Family on Delay
            Discharge of Infant
1300        School Services Parental Permission
5031        Request of Physicians to Withhold or
            Withdraw Life-Sustaining
            Procedures from Terminally Ill Patient
5033        Authorization for Discharge of Minor

1049        Treatment Participation Agreement
7701        Patient/Cardiac Rehabilitation
            Program Agreement
5012        Authorization for
            Funeral Home Release
            Death Certificate
            Certificate of Fetal Death (on
            mother's record)
            Provisional Autopsy Diagnosis
            Final Autopsy Diagnosis
5032        Patient Self Determination Act
2002        Discharge Summary - Handwritten
6004        Patient Demographic Data
6045        Patient Status/Profile

            CONSENT FORMS (cont.)
6046        Comprehensive Care Plan
D:\Docstoc\Working\pdf\1a69aa10-271b-47ed-922f-f7590cce19a6.doc      Health Information Management
Department x29266                     5

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