The medical record handbook
U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, 1985 - Medical - 33 pages
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48 hours Admission Note Admissions Section anesthesia arrangements or plans authorized patient authorized users Center medical record Clinical Center medical Clinical diagnoses Clinical Director Completed records copy current chart date of dictation Date Performed delinquent diagnoses that relate Discharge Summary Follow-up arrangements handwritten health care professionals History and Physical Include all diagnoses include diagnoses Incomplete Medical Record Institute laboratory lead folder legibly medical audit Medical Board Medical Information System Medical Record Committee Medical Record Department medical record request medical record requirements Medicolegal Section ment MICU minimum medical record nurse practitioner nursing staff nursing unit Outpatient Department outpatient encounter outpatient note outpatient visit overprints patient care physician patient encounter area period pertinent physical activity limitations Physical Examination preoperative procedures and dates progress note record request form retrieval return to NIH Section—Room senior attending physician sent submitted surgery surgical suite tion TISSUE EXAMINATION tissue removed unit number verbal order xerographic