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Documents in a New Health Record
Please note, many of these documents contain multiple pages. However, for the purpose of this presentation, I have limited them to only the first page. Also, you may click on the images for an up-close view of the document.
CD Holders
These are used to store CDs from the patient's health care such as recordings of certain procedures or radiology images.
Nurses Discharge Checklist
These must be completed by a nurse when the patient is discharged. It is mandatory, if not completed, the nurse may be audited.
Diet Order
The diet order documents any special instructions pertaining to the patient's diet.
Record of Admission (also known as the Facesheet
This has to be completed upon arrival of a new admit. It is kept at the front of the record for easy reference.
Diagnosis Ranking Sheet
This is the document listing the diagnoses of the patient. They are accompanied by ICD-10-CM codes which are then ranked.
New Admit Clarifications
This form documents new admit clarifications from the collaboration between the RN (Registered Nurse) from the patient's previous hospital, with the RN of Orchard Park.
Resident Admission Checklist
This document is to be completed and signed by a CNA (Certified Nursing Assistant).
Laundry
This document identifies whether the patient's laundry is going ot be done by the facility or by the patient's family.
Inventory of Personal Effects
This documents all of the patient's belongings. At Orchard Park it is filled out by the CNA. This is to prevent any incorrect items.
Additional Patient Information Sheet
Oftentimes, previous hospital discharge sheets are incorrect, so Dianne created this document to collect the patient's personal information to ensure higher accuracy.
Provider Orders for Life-Sustaining Treatment (POLST)
This is a particularly important document in a nursing facility. The POLST is a Medical Order, similar to that of an Advance Directive, documenting what the patient desires if he/she cannot make decisions concerning:
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Whether or not to provide CPR in case of lack of breathing and pulse.
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What kind of medical interventions are desired if the patient is unconscious but still breathing/has pulse, such as life-sustaining medical treatment.
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What they would want in terms of comfort such as measures to relieve pain and suffering.
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If they want to be given artificial nutrition with a feeding tube
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Any other advance directive preferences
Capability of Patient to Sign on their Own Behalf
This documents the attending physician's professional opinion on whether or not the patient is able to comprehend their rights and responsibilities and capable of making medical decisions on their own behalf. If not, another individual needs to be named to make those decisions for the patient.
Preadmission Screening Resident Review (PASRR)
This document is required by the State of Utah to be completed prior to a patient's admission into all Medicare/Medicaid Certified Nursing Facilities, regardless of the payment source. It is a screening evaluation for diagnosing Serious Mental Illness. It contains multiple pages.
Nursing Admission Checklist
This is a form that the CNA has to fill out after the patient arrives. It is a checklist of items such as filling out a prescription sheet for any of the patient's controlled substances, entering them into CareTracker, coordinating with housekeeping to have room ready, and filling out other various documents.
Consent to Treat
This document is a requirement for any patient to receive nursing treatment at the Orchard Park facility. It is acknowledging that any x-ray examinations, laboratory procedures, physical therapy, occupational therapy, speech therapy, respiratory therapy, and any other treatment or medication may be provided by instruction of the physician as part of the general nursing care provided by Orchard Park.
Resident Assessment Form
This form is completed usually an hour after the patient's arrival. It identifies any wounds that the patient has.
Braden Scale
This is used to predict how much a risk the patient is to develop bed sores. It calculates it based on how well the patient can respond to pressure-related discomfort, how exposed the skin is to moisture, degree of physical activity, ability to change and control body positions, nutrition, and how much help is needed to move them.
Fall Risk Assessment
This assessment helps to determine if the patient is a fall risk, and if so, to what extent.
Insomnia Evaluation
This evaluation helps to determine if the patient suffers from insomnia. They usually only complete this if the patient is on medication for insomnia.
Nutrition Hydration Risk Assessment
This assessment identifies any risks the patient may have for malnutriton and/or dehydration.
Pain Assessment
This assessment identifies any pain the patient may have and to what extent.
Device Assessment Tool/ Device Consent Form
This assessment helps to determine if the patient needs any devices such as a body pillow, conce mattress, wander guard (if they have a tendency to wander), etc. It is also a consent form for the patient to use the devices. This is a quarterly assessment.
Resident Influenza Immunization Consent
This is the consent form for giving the patient the influenza vaccine and documents if the patient has had any adverse reactions to the vaccination. Attached to that consent is also a consent to administer the pneumococcal vaccine.
Immunization & PPD Record
This is a permanent record that cannot be removed from the chart. It is a record of the patient's vaccinations. It is especially important as proof that the patient received the TB Skin Test PPD (purified protein derivative), which is per protocol and NOT an optional immunization.
Long Term Resident Care Plan
This document is for long-term care patients. It is on outline of their care plan. It lists needs, problems, measurable goals, and the approach of treatment. It is several pages long.
Short Term Resident Care Plan
This is for short-term patients. It documents their care plan for needs, problems, measureable goals, and the approach of treatment.
Physician's Orders
This is a page with several attached cardon copies. It is where the physician documents any orders for the patient. Often these are prescriptions or slight changes in treatment.
Physician's Admission Orders
This document is usually filled out based on the previous hospital's discharge sheet. It has an attached carbon copy.
Nutrition Risk Review
This is another Assessment that determines any nutrition risks of the patient. It includes a risk scoring guide for pressure ulcers, dehydration, and nutrition.
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Activity Sheet and Schedule
I was not able to get a copy of these, but at the end of the record there are a couple of sheets that document activities that the patient participates in during their stay at Orchard Park.
Please note that these are not all of the documents in the medical record. These are only those that are added to the folder at the beginning of the patient's stay at the facility. Many more are added the the record during their stay such as progress notes, the history and physical, medication and treatment lists, and several more depending on the patient and the services being provided.
