BALANGA MEDICAL CENTER CORP.

MEDICAL RECORDS SERVICE BALANGA MEDICAL CENTER CORP.

MEDICAL RECORDS SERVICE

CHART COMPLETION CHECKLIST

CHART COMPLETION CHECKLIST

Name of Patient:
Hospital no: Name of Patient:
Consultant: Hospital no:
Resident on Duty: Consultant:
Date Admitted: Resident on Duty:
Date Admitted:
Please put a ( ) check on an appropriate box.
Please put a ( ) check on an appropriate box.
1. Consultant YES N/A NO
1. Consultant YES N/A NO

-Final Dx
-OR Technique
-Final Dx
-Signature –Consent for
-OR Technique
Surgical Operation
-Signature –Consent for
Procedure/ Treatment
Surgical Operation
-Record of Operation
Procedure/ Treatment
-Progress Notes
-Record of Operation
(Course in the ward)
-Progress Notes
-Discharge Plan
(Course in the ward)
-Discharge Plan
2. Anesthesiologist
2. Anesthesiologist
-Pre-Anesthetic evaluation sheet
-Anesthesia Record
-Pre-Anesthetic evaluation sheet
-Consent for anesthesia management
-Anesthesia Record
-Surgical Memo/Record of operation
-Consent for anesthesia management
-Surgical Safety checklist
-Surgical Memo/Record of operation
-Surgical Safety checklist
Please put a ( ) check on an appropriate box.
Please put a ( ) check on an appropriate box.
3. Resident
3. Resident
-Admitting Hx – (to include past
Medical Hx and family Hx)
-Admitting Hx – (to include past
-Discharge Summary
Medical Hx and family Hx)
-Intra- op counting sheet for signature
-Discharge Summary
-Progress Notes – (course in the ward)
-Intra- op counting sheet for signature
-Post Anesthesia Record Checklist
-Progress Notes – (course in the ward)
-Post Anesthesia Record Checklist
4. OR Nurse / NOD (course in the ward)
4. OR Nurse / NOD (course in the ward)
-Consent for Admission
-OR Notes
-Consent for Admission
-Signature: - Pre- operative care checklist
-OR Notes
-Consent for surgical operation/ procedure
-Signature: - Pre- operative care checklist
-Consent for Anesthesia management
-Consent for surgical operation/ procedure
-Intra-op Counting Sheet
-Consent for Anesthesia management
-Intra-op Counting Sheet
Others:
Others:
For any item not accomplished at patients discharge, indicate
reason(s)
For any item not accomplished at patients discharge, indicate
reason(s)

5. Items 1-4 completed confirmed by:

5. Items 1-4 completed confirmed by:
Nurse in charge /Date Signed
Nurse in charge /Date Signed
6. Items 1 -5 completed/ confirmed by:
6. Items 1 -5 completed/ confirmed by:

Medical Record’s Clerk/Date Signed

Medical Record’s Clerk/Date Signed