Read CHART ORDER LIST text version

CHART ORDER LIST Revised 2003 Administration J2020 Disclosure Tracking Log (on the left side under administration) H003 Patient Registration H151 OB Discharge Summary J629 Newborn Discharge Summary Discharge Summary H128 Authorization & Agreement J1110 Receipt of Notice of Privacy Practices J610 Important Notice A,B,C H341 Discharge Prescription J983 Secondary Prevent J439 Flight Record J440 Physician's Certificate for Transport J1070 Transfer Agreement J076 Inter-Facility Transfer Form J100 Record of Possession of Medico-Legal Substances H101 Record of Examination-Alleged Rape J453 Report of Suspected Adult Abuse/Neglect H889 Report of Suspected Child Abuse/Neglect J987 Pre-Discharge Evaluation of Risk to Self and Others J635a Discharge Instructions J635s Discharge Instructions (Spanish) H646 NICU Discharge Instructions J677 Medication Information J686 Endoscopy Discharge Instructions J588 Autopsy Report Master Treatment Plan Attendance Record Master Treatment Plan Nursing Care Record OR RECORD (in date order of procedures) J807 Blue History & Physical H445 Green Pre-Operative Checklist Site Verification Checklist H299 Anesthesia Record H245 Anesthesia Record Continuation Sheet H354 Anesthesia Record H345 Anesthesia Record Continuation Sheet J821 Labor Epidural Analgesia Record H720 Operative Procedures Notes H425 OR Patient Record Operative Report Brief OP Note H488 Surgical Pathology Report J400 Perioperative Nursing Record J1022 PACU Flowsheet J384 PACU Flowsheet J407 OB Recovery Room Sheet J694 Gamma Knife Flowsheet J176 Clinical Record Fibroptic Bronchoscopy H742 Endoscopy Diagrams ­Upper GI Tract H743 Colonoscopy Results Endoscopy Report J490 Endoscopy Lab Flowsheet D300 Manometry/ph Monitoring J910 Diagnostic Radiology Flowsheet H455 Cardiopulmonary Perfusion Record J661 Invasive Cardiology/Electrophysiology Report J514 Cardiac Cath Patient Report Cardiac Cath Report J981-1 Electrophysiology Serv. Nursing Flowsheet J981-2 Electrophysiology Serv. Nursing Flowsheet Cont. J660 Cardiology Procedure Report J840 Electrophysiology Pacer Record * ALL PHYSICIAN'S ORDERS FILE IN DATE ORDER * J337 Infant Delivery Record J488 ED Physician's Trauma Orders J732 ED Chest Pain Acute Myocardial Infaraction Phy/Pt care orders H310 Physician's Orders To Be Put in Date Order: H310E Physician's Orders ­ date order H310H Physician's Orders ­ date order University Physician/Patient Care orders Acute Ischemic Stroke Admission Orders H657 Standing Orders for Initial Tx J426 Adult TPN Physician's Orders J428 Pediatric Neonatal TPN Physician's Orders J443 Chemotherapy Orders J519 Antimicrobial Orders J529 Chromosome Analysis-Genetic/Prenatal Orders J530 Chromosome Analysis-Oncology Orders J569 Respiratory Therapy Order Sheet J621 Anti-Endotoxin Monoclonal Antibody Order J701 Epidural Physician's Order J705 Peripheral Nerve Block Patient Controlled Analgesia J706 IV Patient Controlled Analgesia Physician/Patient Care Orders J707 NICU Admission Physician/Patient Care Orders J729 Postoperative Anesthesia Physician/Patient Care Orders J994 J510 Vascular Laboratory Examination J1015 Echocardiogram Request H330 83 Pulmonary Function Requisition J0002 Non-Gynecologic Cytopathology H489 Gynecologic Cytopathology J997 Alcohol Dep Protocol J998 Polydrug Dep CX01 Signature Record Critical Pathways

HISTORY & PHYSICAL/CONSULTS J492 ED History & Physical ED Attending Note J679 Maxillofacial Trauma Evaluation J499 Trauma Admission J900 Spine Clearance J961a-f Orthopaedic Surgery H&P J441 Labor & Delivery Summary H076 Short Stay Re-Admission Record J698 Obstetric History & Physical J908 Labor Progress Record H315 Consultation Request H336 Psychological Evaluation J669 Psychosocial Assessment J671 Initial Social Work Assessment J683 Retinopathy of Prematurity Consultation J203 Medical Consultation J628 Newborn Admission J1060 1-4 2, 3, & 4 Neonatal/Pediatric Transport H&P Transport Record J1057 Neonatal Intensive Care Unit Progress Note J975 Neonatal Intensive Care Resident H&P J912 Children's Hospital Admit Note H291 History/Physical/Progress Notes D601 Child Life Progress Note ­ date order J1005 Procedure Form (filed in date order w/progress notes) J288 Progress Notes J690B Psychiatric Night Shift Nursing Progress Report UKPHO Pediatric Hematology-Oncology Daily Care Note ­ date order in Progress Notes Neonatal Intensive Care Unit Discharge Evaluation J236 CPR Record-Code 500 J236a Pediatric Code Sheet 500 J1096 Supportive Oncology Services (S.O.S) Screening Instrument J2006 Post-operative/Progress Notes

EKG (and other special test) EKG Reports J008 EKG Strips Echocardiography Report J282 Adult Echo Report J527 Adult Echo Report Transesophageal Echocardiography Flow Sheet (blue) J536 Transesophageal Echo Monitoring Report J397 Stress Test Report Holter Monitoring Report To be put in date order: H312 EEG Report Electromyography J319 NCV Nerve Conduction Velocity J344 Bone Marrow Processing forms J429 Adult Bone Mineral Density J430 Pediatric Bone Mineral Density J566 Evoked Potential Report Multi-channel Sleep Recording Report J401 Sleep Study Report J664 Cardiopulmonary Exercise Test Report OB High Risk form Antepartum Testing Radiology/Radiation/Nuclear Medicine Radiology Reports J264 Radiology Special Procedures J408 Duplex Ultrasound Cerebrovascular Exam J172 Tx/Implant Summary Radiation Implant Summary

Respiratory/ Rehabilitation J817 Initial Evaluation J070 Resp. Therapy Tx Record J089 Resp. Therapy Ventilator Record J316 Pediatric Ventilator Record J541 BiPap S/T Record H331 Spirometry & Lung Volume H538 Rehabilitation Progress Notes H789 Asses. Plan of Care & Progress Notes J959 Gait Training J952(1&2) Splint Evaluation J474 Respiratory Care Services Metabolic Study D912 Bronchial Hygiene Evaluation H330 Pulmonary Function Test J321 Pulmonary Function Studies Pulmonary Function Report J432 Hyperbaric Oxygen Therapy H&P Screen J433 Record of Hyperbaric Treatment Exposure J955 Physical Therapy Cardiac Evaluation J951 Cardio Pulmonary/Transplant Evaluation J395 Rec. Therapy Initial Assess. & Activity Evaluation J667 Occupational Therapy Evaluation

Medication Records J359 Pain Management Medication Record J386 Notice of Sedation J1003 A&B Ped, Critical Care & Sedation Service Frequent Assessment Monitoring Records J525 PCS Paper (medication sheet) J1099 Pain Assessment Management Flow Sheet J359 Pain Management PCA Flow Sheet J962 Amin. & Vanc. Pharmacokinetic Monitoring Graphics J110 Emergency Transfusion Request & Release ED Transfusion Record H964 Blood Bank Transfusion Reaction H288 Transfusion Reaction Report J485 Vital Signs Flowsheets J486 Intake/Output Flowsheets J071 Intake Flowsheet J696 ECMO Laboratory Flowsheet J697 ECMO Flowsheet ECMO Shift CT ICU Flowsheet J475 Initial Nutrition Assessment J483 Nutritional Flow Sheet J009 Sedative Hypnotic Withdrawal Sticker J115 OPIOD Drug Withdrawal H152 Labor Flowsheet H959 Special Fluid Balance Record H960 Newborn Data Flowsheet H961 Special Clinical Nurses Record J221 Seizure Flowsheet J261 Pediatric ICU Flowsheet J262 Pediatric ICU Flowsheet J905 PT. Event Record D255 Initial Phy Assess. For Behavioral Health Care J518 Restraint Flowsheet Authorizations H318 Authorization for Special Procedures WOO4 Request for Restrictions Regarding Treatment, Payment and Health Care Operations J1101 Consent for Treatment of Cancer with Chemotherapy H321 Authorization for Autopsy H322 Authorization for Leaving the Hospital AMA H324 Authorization for Therapeutic Abortion H326 Authorization for Disposal H328 Authorization to Take Photographs H357 Authorization for Removal of Anatomical Gifts Consent for Bereavement Services H906 Bequeathal of Body J127 Authorization for Neonatal Transport J299 Perinatal Sibling Visitation Record J427 Auth. to Allow Others to Interact with Infant/Child J431 Auth. For Release of Birth Announc. To the Media J436 Temporary Release form the Hospital J438 Reverse Transport Agreement J468 Hepatitis B Vaccine J489 Voluntary Consent to Hepatitis B Vaccine J559 Newborn Screen Informed Release J602 Vaccine Consent Rejection of Blood Transfusion LB146 Newborn Maturity Rating and Classification Weight Chart J567 Premature Infant Growth Chart Valuables Release Newborn Identification Record (foot) Birth Certificate (all four forms) Hearing Risk Screen Death Certificate (all three forms)

Laboratory Laboratory Report papers (originals) Outside labs (outside referrals) PKU results (stick on another sheet) Hemodialysis D350 Hemofiltation Flow Sheet J425 Peritoneal Dialysis Continuous Renal Replacement Therapy J125 Drug Monitoring To be put in form # order H before J H249 Virology H489 Cytopathology Consultation H031 Coagulation H035 Bacteriology J326 Histopathology J339 Drugs of Abuse Screen J349 Serology Requisition (if HIV + only) J496 Cytogenetics Report J497 Molecular Diagnostic Lab report J498 Flow cytometry Lab J532 Laboratory Consultation J579 Cytopathology Report (file w/surgery if matches date) Vascular Lab

Nursing Notes J599 ED Nursing Care Record J491 ED Nursing Care Record Continuation Level of Care Scoring System J494 Trauma/Critical Care Nursing Record J491 Trauma/Critical Care Nursing Record Cont. J372 Nursing Neonatal Transport Flowsheet J521 23 Hour Admission Record J538 Pediatric 23 Hour Admission Record J015 Nursing Data Base/Shift events update (All except for Psych) J1046 Pt Care Observation/Assessment* J011 Neonatal ICU Nursing History J014 Nursing Care Plan (Kardex) J445 Patient Care Plan Continuation J597 PACU Standard Care Plan J806 PACU Acuity J690 Patient Care Plan J691 a,b,c Patent Care Plan Continuation J695 Diagnostic Imaging Nursing Notes J520 Psychiatry nursing Rounds J687 Nursing Group Notes ­Psychiatry J1025 Inpt. Psychiatry Group Therapy Notes J092 Neurological Flowsheet J332 Neurovascular Assessment J368 Transitional Nursery Flowsheet J292 Patient Care Record H962 Pediatric Patient Care Record J005 Burn Unit Nursing Notes J006 Estimation of Size of Burn by Percent J391 Nursing Evaluation J462 Nursing Initial Shift Assessment J335 Antepartal Nursing Discharge Summary J336 OB/Newborn Nursing Discharge Summary J241 Pediatric Patient Summary Teaching Sheet J1078 Interdisciplinary Patient/Family Education H440 Home Health



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