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    Key For Record Review ANNEX-II

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    mehwishbilal7800
    1. The document is a record review form for evaluating healthcare records. It contains 31 criteria grouped under various categories like patient assessment, consent forms, anesthesia notes, operation details, and outcome. 2. The form requires checking if the criteria are complete, legible, and contain required elements like date, time, signature and stamp. It also allows marking entries as red/yellow based on deficiencies. 3. The record review evaluates healthcare records on criteria like documentation of patient identification, history, diagnosis, treatment plan, consent forms, anesthesia monitoring, operative notes, post-operative plan and discharge details.

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    Key For Record Review ANNEX-II

    Uploaded by

    mehwishbilal7800
    3 views3 pages
    1. The document is a record review form for evaluating healthcare records. It contains 31 criteria grouped under various categories like patient assessment, consent forms, anesthesia notes, operation details, and outcome. 2. The form requires checking if the criteria are complete, legible, and contain required elements like date, time, signature and stamp. It also allows marking entries as red/yellow based on deficiencies. 3. The record review evaluates healthcare records on criteria like documentation of patient identification, history, diagnosis, treatment plan, consent forms, anesthesia monitoring, operative notes, post-operative plan and discharge details.

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    key for Record Review ANNEX-II

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    1. The document is a record review form for evaluating healthcare records. It contains 31 criteria grouped under various categories like patient assessment, consent forms, anesthesia notes, operation details, and outcome. 2. The form requires checking if the criteria are complete, legible, and contain required elements like date, time, signature and stamp. It also allows marking entries as red/yellow based on deficiencies. 3. The record review evaluates healthcare records on criteria like documentation of patient identification, history, diagnosis, treatment plan, consent forms, anesthesia monitoring, operative notes, post-operative plan and discharge details.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    3 views3 pages

    Key For Record Review ANNEX-II

    Uploaded by

    mehwishbilal7800
    1. The document is a record review form for evaluating healthcare records. It contains 31 criteria grouped under various categories like patient assessment, consent forms, anesthesia notes, operation details, and outcome. 2. The form requires checking if the criteria are complete, legible, and contain required elements like date, time, signature and stamp. It also allows marking entries as red/yellow based on deficiencies. 3. The record review evaluates healthcare records on criteria like documentation of patient identification, history, diagnosis, treatment plan, consent forms, anesthesia monitoring, operative notes, post-operative plan and discharge details.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    of 3

    Name of HCE, Date of inspection,

    Sr.# 1 2 3 4 5 6 7 8 9 10 Red/Yellow
    1 MR #
    Is it mentioned on every record
    (Lab, X Ray reports,informed
    2 consent, Discharge,referel slips) etc.

    All entries by authorized person as


    3 per notification
    4 Every record has date,
    Time
    5 less than 05
    entries
    6 Sign
    7 Stamp/name/Designation 1-2 entries
    Pre anesthesia assessment by
    8 anesthetist. Covering evaluation,
    ASA scoring, etc.

    Anesthesia plan documented as per


    9 assessment
    Pre operative re-evaluation
    10 documented.
    Anasthesia informed consent
    11 obtained
    During Anesthesia monitoring
    documented. (HR,Cardiac
    Rythem,RR,BP,O2
    saturation,Airway
    12 security/patency/level of
    anaesthesia) Etc.

    Patient identity documented.


    13 (Calling out time protocol)
    Post anesthesia monitoring
    documented. (BP,Pulse,RR,Level of
    14 conscious,Pain stimulus)
    Recovery area monitoring
    documented.Discharge criteria from
    15 recovery documented.(by
    anesthetist/trained nurse)

    16 Pt History,physical exam,
    17 Provisional diagnosis 1-2 entries
    18 Informed Consent
    Documented patient identification
    19 to prevent worng
    pt/surgery/side/site etc.

    brief Operative notes with Date,


    20 time, signed, stamp/name

    21 Post operative plan documented.


    Treatment orders, post op orders in
    22 uniform location.

    23 Medicaton order are clear,


    24 legible,
    25 dates, 1-2 entries
    26 timed
    27 Name,signed
    28 Verbal orders documentation
    Medication chart documented,
    Name of drug, strength, route,
    29 time, signed by authorization staff

    30 General consent form


    31 Blood transfusion consent
    HCE Name
    Record Review Formate

    Pt, Assessment Consent forms Daily Progress notes Anaesthesia notes Operation Out come

    MR# Description Treatment plan Treatment


    Diagnosi sheet
    History Exam s General Anaesthe
    sia Surgery Blood
    transfusion Doctors Nusing staff Pre inter post op notes post
    plan
    op Discharg Referrel Death slip
    e slip slip

    Completeless

    Legible

    Date, time, sign


    stamp

    Completeless

    Legible

    Date, time, sign


    stamp

    Completeless

    Legible

    Date, time, sign


    stamp

    Completeless

    Legible

    Date, time, sign


    stamp

    Completeless

    Legible

    Date, time, sign


    stamp

    Completeless

    Legible

    Date, time, sign


    stamp

    Completeless

    Legible

    Date, time, sign


    stamp

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