MEDICAL RECORD REVIEW FORM HOSPITAL NAME :
<print name of hospital here>
Medical Record 1 STD
<reviewer enters date of review here>
Date Of Review :
Medical Record 2
Medical Record 3
Medical Record 4
Medical Record 5
#
#
#
#
#
DX:
DX:
DX:
DX:
DX:
TOTAL Y/N
DOCUMENTATION REQUIREMENT
Y
N
NA
Y
N
NA
Y
N
NA
Y
N
NA
Y
N
NA
Y
N
OTHER COP.8.7
The transplant program updates clinical information in the transplant patient’s medical record on an ongoing basis
COP.9.2
The transplant program documents organ compatibility confirmation in the living donor’s medical record
ASC.5
Anaesthesia Plan
ASC.5.1
The anesthesiologist or another qualified individual provides and documents the education
ASC.6
Each patient’s physiological status during anesthesia and surgery is monitored according to professional practice guidelines and documented in the patient’s record
ASC.6.1
Each patient’s postanesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established criteria Assessment information that supports the planned procedure
ASC.7
Preoperative diagnosis Planned surgical procedure
MEDICAL RECORD REVIEW FORM HOSPITAL <print name of hospital here> Form credit: Joint Commission International, 2014, Hospital Survey Process Guide (HSPG), 5th edn, JCI, USA (Modified version by VIJAYAN RAGAVAN, Medical Records Pals Malaysia)
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