CHRONOLOGICAL ORDER – Surgical patients

1. Inpatient DR Assessment form

2. DRS orders
3. Progress notes – SOAP format
4. Instructions chart
5. Vitals chart
6. Drug chart, Drug reconciliation form
7. GRBS chart
8. I/O chart
9. OT notes
10. All investigation reports
11. Anaesthesia record – Pre op, Intra operative record
12. Aldrete score chart
13. Surgery, Anaesthesia, Blood transfusion and all other consent forms
14. ICU record
15. Initial assessment form Nurses
16. Nurses record.
17. Physiotherapist chart
18. Nutritional assessment form
19. All other forms & formats

CHRONOLOGICAL ORDER – Medicine cases

1. Inpatient DR Assessment form

2. DRS orders
3. Progress notes – SOAP format
4. Instructions chart
5. Vitals chart
6. Drug chart, Drug reconciliation form
7. GRBS chart
8. I/O chart
9. All investigation reports
10. ICU record
11. Initial assessment form Nurses
12. Nurse’s record.
13. Physiotherapist chart
14. Nutritional Assessment form
15. All other forms & formats