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records. The JCAHO requires hospitals to demand that admission and discharge be timely completed by physicians as a condition of the physician maintaining hospital staff privileges. The dates of dictation of notes of events should always be compared to the dates of the events they describe, particularly when there are no handwritten notes of the same event, as would otherwise be expected.
Face sheet
The face sheet or cover sheet of the hospital record usually records census information and personal identification information about the patient, and usually also contains information about collateral sources of payment. It may be particularly important in the early evaluation of the case to determine whether the
basis for a governmental lien may exist, such as MediCal or Medicare, which then obligates the lawyer to notify the agency and honor the lien.
Admission and discharge summary
This document usually contains a history of the immediate hospital episode, summarily documenting the admitting status of the patient, the reason for the admission, and what was done during that hospitalization, as well as the discharge status of the patient. It records the patient’s acute and chronic medical conditions, and events which cause a significant change in the status of the patient during the hospitalization. It may also contain some valuable information about prior medical events which led up to the hospitalization, and conditions
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which were a significant concern in providing health care, such as complications and untoward events. Physician-caused injury is frequently referred to as an “iatrogenic” event.
Operative report
The surgeon in charge of any operation performed in a hospital or outpatient surgery center is obligated to generate a report giving the details of the procedure, including the pre- and post-operative diagnosis, the proposed procedure, any changes from that preoperative plan, the anesthesia used, who was present, and a description of the significant events which occurred. Most often, they are dictated by the surgeon themselves, and transcribed by the hospital transcription service. Oftentimes, the reports of the surgical procedure follow a canned script, which can be rather easily detected by looking for the presence or absence of detail: the less detailed, the more likely canned. A plaintiff ’s attorney can ask a medical witness to interpret the details of the report, which generally has the impact of impressing on jurors the seriousness of the patient’s condition requiring surgery.
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Physician’s Orders
These pages of the medical record are generally handwritten, except in some more modern EMRs, containing templates for usual medications ordered for similar procedures which the physician usually checks off. They contain a host of abbreviations and symbols, and may also show the time they were made, and how they were made. Orders may be direct, written by the physician herself, directing specific conduct, medications, testing, etc.; or they may be verbal orders, designated as such: “V.O.”, or “T/O”, meaning orders made by a physician over the telephone to a nurse. In all instances, the person writing the order entry should sign the order, and the person making the order should countersign the latter kinds. Nurses should also indicate on the physician order form when the orders are carried out. These may
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