Worksheet for Scavenger Hunt (1) (2)
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Sinclair Community College *
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2211
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Health Science
Date
Feb 20, 2024
Type
docx
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7
Uploaded by SuperHumanHyena3976
1
MEDICAL RECORD SCAVENGER HUNT WORKSHEET
Student Name:
Patient Name:
Patient Medical Record Number:
Based upon Joint Commission standards
Rating ✔
- met x – failed N/A – not applicable
Rating based on information included on the following page number(s)/ documentation in the medical record
MM: Medication Management
Does the medical record reflect the following:
-Age?
✔ Yes, Pg, 1
-Sex?
✔ Yes, Pg 1
-Diagnoses?
✔ Yes, Pg 1
-Allergies?
✔ Yes, Pg 3, Pt has no known allergies -Height and weight?
✔ Yes, Pg 3, Under DATA/ Last weight -Lab results?
✔ Yes, Pg 4
PC: Provision of Care, Treatment, and Services
Does the record include an H&P examination no more than 30 days prior to, or within 24 hours after,
registration or inpatient admission? Before surgery or a procedure requiring anesthesia?
✔ Yes H&P 1/17
Does the H&P
examination address the following:
-Chief complaint?
✔ Yes, Pg 7, Subjective, Chief complaint, Fall -Present illness?
✔ Yes, Pg 7, Subjective, History of Present illness
-Past/family/social history?
No, Stated on Pg 15, Family History, History reviewed. No pertinent family history. Family History has its
2
Based upon Joint Commission standards
Rating ✔
- met x – failed N/A – not applicable
Rating based on information included on the following page number(s)/ documentation in the medical record
information on Pgs 21-22.
-
Body system inventory?
No
-Psychosocial needs? (i.e. psych needs, social
needs)
No
-Physical Exam?
No, the information is located in ED Notes Is there a bridge note? (Hint: A bridge note is required when the H&P occurred prior to admission.)
Yes, Pg 43
Does the record contain a functional screening within 24 hours after inpatient admission? (Hint: Is there an Occupational Therapy
Evaluation and a Physical Therapy Evaluation) ✔ Yes, Pg 23, Acute Physical Therapy Evaluation. Pg 30, Occupational Therapy
Does staff provide patient care prior to beginning operative or other high-risk procedures, such as administration of deep sedation or anesthesia?
Yes, Pg 39, Located in the
procedural description
-Is there a pre-sedation or pre-anesthesia assessment documented in the medical record?
(Hint: Locate the ASA Score.)
✔ Yes, Pg, 54, Pt level 3
-Is there documentation in the medical record that the patient is reevaluated immediately before administering moderate or deep sedation
or anesthesia? (Hint: Look for the “Events” section in the anesthesia record.)
✔ Yes, Pg 51, Located under Events. Pg. 52, Pre-
Sedation/Anesthesia Assessment
-Is there a “Time Out” session documented prior
to surgery? (Hint: Look for the “Events” section in the anesthesia record.)
No
Do staff monitor patients during operative or other high-risk procedures and while administering moderate or deep sedation or anesthesia?
Yes, Pg. 52, Assessment -Is there documentation in the medical record that the patient’s oxygenation, ventilation, and circulation are monitored during operative or ✔ Yes, Pg. 52-56 Written confirmation of vital checks during the
3
Based upon Joint Commission standards
Rating ✔
- met x – failed N/A – not applicable
Rating based on information included on the following page number(s)/ documentation in the medical record
high-risk procedures and/or moderate or deep sedation?
procedure. Graphic display of monitored vital
signs -Does a qualified LIP (licensed individual practitioner…such as an anesthesiologist) discharge the patient from the recovery area or from the hospital? (Hint: Is there a LIP signature
in the post-anesthesia note?)
✔ Yes, Pg. 54, Post anasatic
note, Electronical signed electronic by Craig T, DO RC: Record of Care, Treatment, and Services
-Does the information in the medical record support
the patient’s diagnosis and condition? (Hint: If the information is supportive, indicate “met” and indicate “all pages”)
✔ Yes, Met all Pages -Are dates included for all entries in the medical record? (Hint: For the purposes of this assignment, include only physician progress notes)
✔ Yes, Pg. 40-45, Dates for all Physician Profess Notes -Are all entries in the medical record timed? (For the purposes of this assignment, include only the progress notes.)
✔ Yes, Pg. 40-45, Dates for all Physician Profess Notes -Are electronic signatures date-stamped?
✔ Yes, Pgs, 6, 13, 19, 22, 37,
40-45, 49-50
-Are orders dated and signed by the ordering physician or another practitioner who is responsible
for the care of the patient?
✔ Yes, Pg. 6, Discharge orders, Miten N Pepsodent, MD, 3/20/20XX 11:17 AM. Pg. 13 Miten N Pepsodent, MD, 1/17/20XX 1:40 PM -Does the time frame for record completion exceed 30 days after discharge? (For the purposes of this assignment, consider only the completion date of the discharge summary.)
No, Pt admitted on 1/17, discharged on 1/20, but the discharge papers were not signed till 3/20 Is the following clinical information included in the medical record?
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Based upon Joint Commission standards
Rating ✔
- met x – failed N/A – not applicable
Rating based on information included on the following page number(s)/ documentation in the medical record
-Admission reason
✔ Yes, Pg 1, Medical Synopsis, Reson for admisson/cheif complaint
-Initial diagnosis, diagnostic impressions, or conditions?
✔ Yes, Pg 1, Medical Synopsis, Principal diagnosis, and hospital problem list
-Consultative reports?
No, requests were placed on Pg, 17, but no reports were filed. -Emergency care, treatment, or services provided to the patient before arrival? (For example, care provided in an ambulance.)
No
-Treatment goals, plan of care, and revisions to the plan of care? (Hint: Look for a treatment plan in the H&P.)
✔ Yes, Pg. 7, Assessment and Plan
-Is informed consent for treatment included in the record?
✔ Yes, Pg. 70, It is signed, dated, and time stamped -Does the record contain any conclusions arrived at once care, treatment, and services ended, including final disposition, conditions, and instructions for follow-up care?
✔ Yes, Pg. 1, Discharge Disposition
Pg. 2, Pertinent finding requiring f/u
Pg. 5, Disposition, Follow-up appointment -Are the operative or other high-risk procedures and administration of moderate or deep sedation or anesthesia documented in the medical record?
✔ Yes, Pg. 51, Anesthesia Type -Does the H&P provide the provisional diagnosis before
the patient undergoes an operative or other high-risk procedure?
✔ Yes, Pg 7, Subjective
5
Based upon Joint Commission standards
Rating ✔
- met x – failed N/A – not applicable
Rating based on information included on the following page number(s)/ documentation in the medical record
Is the following information included in the operative report and/or other documentation:
-Name of LIP who performed the procedure and
names of any assistants?
Yes, Pg. 51, Responsible Staff
-Name, description, and findings of the procedure?
Yes, Pg, 38, Left proximal
femur intramedullary nail,
because of Left intertrochanteric hip fracture, fixes with the implant. -Estimated blood loss?
Yes, Pg. 38 ESTIMATED BLOOD LOSS
Less than 100 mL.
-Specimens removed, if any? (Hint: If no specimens removed, indicate N/A.)
N/A
-Postoperative diagnosis?
Yes, Pg, 38, Left intertrochanteric hip fracture. -Is there an immediate progress note recorded?
(Hint: Locate the Immediate Post-op Note form. Using Cntl/F to find General Post-op may help.)
Yes, Pg. 50, Post-Op Note
-Does the immediate post-op note contain the name of the primary surgeon?
Yes, Pg. 50, Richard T Fixodent, MD, 1/18/20XX 4:44 PM
- Does the immediate post-op note in the physician progress notes contain the name, description, and findings or the procedure?
Yes, Pg. 50, List on page 50
- Does the immediate post-op note in the physician progress notes contain estimated blood loss?
Yes, Pg. 50, Less than 100ml
- Does the immediate post-op note in the physician progress notes contain specimens removed, if any? (Hint: If no specimens N/A
6
Based upon Joint Commission standards
Rating ✔
- met x – failed N/A – not applicable
Rating based on information included on the following page number(s)/ documentation in the medical record
removed, indicate N/A.)
-Does the immediate post-op note in the physician progress notes contain the postoperative diagnosis?
Yes, Pg. 50, left intertroch hip fx
-Does the postoperative documentation in the physician progress notes include the name of the LIP (Licensed Independent Practitioner...such as a physician) responsible for discharge?
No, Postoperative is only signed by Richard T Fixodent, MD. Not signed by discharge physician Miten N Pepsodent, MD.
Is the following contained in the discharge summary:
-Reason for hospitalization?
Yes, Pg. 1, Reason for admission/chief complaint: L hip fracture -Procedures performed?
Yes, Pg. 2, Procedure/test
performed: ORIF
-Care, treatment, and services provided?
Yes, Pg. 2, Hospital course and treatment
-Patient’s condition and disposition at discharge?
Yes, Pg. 6, ECF, Fair
-Information provided to the patient and family
?
No
-Provisions for follow-up care?
Yes, Pg. 2, Medications on discharge RI: Rights and Responsibilities of the Individual (RI)
-Is informed consent for surgery obtained prior to surgery...except for emergency surgery?
Yes, Pg. 71, Appropriately
signed and dated -Is consent for treatment obtained?
Yes, Pg. 70, Appropriately
signed and dated
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Based upon Joint Commission standards
Rating ✔
- met x – failed N/A – not applicable
Rating based on information included on the following page number(s)/ documentation in the medical record
-Is consent for anesthesia obtained?
Yes, Pg. 72-73, Appropriately signed and dated Notes (optional):