Get Medical Record Important Procedures To Follow:

Filling out the Medical Record Important Procedures To Follow form is a crucial step in ensuring that all necessary medical records are accurately documented and submitted. This guide provides clear, step-by-step instructions to assist you in completing this form efficiently and correctly.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form. This will open the document in your editing tool.
2. Begin with entering the final diagnosis on the face sheet at the time of the patient's discharge. Ensure that this field is completed before finalizing the form.
3. Dictate or handwrite the history and physicals within 24 hours of the patient's admission. For elective admissions, make sure these documents are available upon admission.
4. To meet Medical Board Policy, ensure that dictated history and physicals are completed at least 72 hours before elective admissions, so they are ready 48 hours in advance.
5. Remember that any history and physical completed over 7 days prior to admission must be updated. Use the provided stamp for updates.
6. Complete an addendum if there are changes to the patient's present condition after the initial history and physical.
7. When documenting for a same day surgery patient or one requiring less than 24 hours of hospital stay, utilize the short stay form.
8. Immediately after the surgical procedure, dictate the operative reports and write a postoperative progress note. Ensure these are completed within 24 hours.
9. Dictate the discharge summary at the time of the patient’s discharge.
10. Ensure that no medical record is removed from the hospital unless legally subpoenaed.
11. Complete and submit the coded information, ensuring all chart elements are available for timely coding and DRG assignment.
12. To address incomplete medical records, file them appropriately and ensure regular follow-ups to complete charts as necessary.
13. Follow the dictation procedures outlined and ensure you use the correct dictation number assigned to you.
14. Participate in training for the electronic signature system if you have not already done so, and remember to create your personal pin number.
15. If you need to request patient information, ensure you follow confidentiality protocols and complete all necessary authorizations.
16. Finally, save your changes, download, print, or share the completed form as necessary to ensure it is properly submitted.

Complete your Medical Record Important Procedures To Follow form online today for efficient and accurate documentation.