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CHART ASSEMBLY OF ACTIVE MEDICAL RECORDS
PURPOSE:
To ensure that all forms within Medical Records are arranged in uniform
and consistent order.
DEFINITION:
Chart assembly is a standard arrangement of forms for a Medical Record.
PROCEDURE:
The Medical Record is divided into sections with the indicated forms
filed behind each section.
Top Sections
Binder--Resident I.D. picture in inside pocket.
Admitting Record
Admission Records
Nursing History and Evaluation
Nutritional Assessment Form
Recreation Initial Interview From
History and Physical
Current Physical
Original Physical (done on Admission)
Medical Plan of Care
Recertification and Review of Plan Care
Abnormal Involuntary Movement Scale (AIMS)
Physician's Orders
Physician Order Sheets (ensure any written carbon copies are sent to
Pharmacy)
Physician Progress Notes
Physician Progress Notes
Dietary Progress Notes
Dietary Communication Slips
Activities Progress Notes
Nurse's Progress Notes
On-going Nurse's Notes relative to affairs of patient care (including
Nursing Summaries)
Assessment of Decubitus Ulcer Potential
Assessment of Bowel and Bladder Training
Assessment for Restorative Nursing Care
Care Record and Restraint Check Records
Vital Signs
Clinical Chart
Vital Sign
Flow Sheet
Intake and Output Record
Seizure Record
Medication and Treatment
Medication and Treatment Records
Insulin Control Sheets
Release of Pass Medications
Lab and Special Reports
Lab, X-Ray, EKG slips/reports
Immunization Record
Rehabilitation and Therapy
Physical Therapy Reports
Occupational Therapy Reports
Speech and Audiology Reports
Consultations
Consulting Pharmacist Flow Sheet
Miscellaneous Consultant Reports
Psychiatric Reports
Dental Reports
Podiatric Reports
Social Service
Social Service Records
Miscellaneous
Electrical Appliance Safety Check
Receiving and Inventory Report
Sign Out Sheets for Residents
Inter-Disciplinary Behavior Log
Activities Attendance Record
Consent, Authorization and Release Forms
Release of Responsibility for Leave of Absence
Transfer Forms
Clothing Inventory
Care Plans
Health Care Plans (Nursing, Activities Social Services, Dietary,
Physical Therapy and Occupational Therapy)
Case Conference Attendance Roster
Resident Biographical Data Form
Case Conference Evaluation Form
Known allergies and sensitivities on label of chart cover.
Note in back of chart indicating when charts were purged, by whom, and
where purged portions of the chart can be located.
MEDICAL RECORDS - 35-03-006
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