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    Active File Audit For Hospital

    Uploaded by

    Rahul Indalkar
    The document is an audit report listing missing or incomplete documentation for a patient's hospital records. It identifies 17 parameters for which documentation is either missing or incomplete, including consent forms, checklists, records from the operating room and intensive care unit. The nurse administrator is notified that documentation is missing the patient's and relative's signatures and dates in several areas, as well as other incomplete details like risk factors and languages. The audit serves to ensure all required documentation is properly completed for the patient's file.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    Active File Audit For Hospital

    Uploaded by

    Rahul Indalkar
    674 views4 pages
    The document is an audit report listing missing or incomplete documentation for a patient's hospital records. It identifies 17 parameters for which documentation is either missing or incomplete, including consent forms, checklists, records from the operating room and intensive care unit. The nurse administrator is notified that documentation is missing the patient's and relative's signatures and dates in several areas, as well as other incomplete details like risk factors and languages. The audit serves to ensure all required documentation is properly completed for the patient's file.

    Original Description:

    Active File Audit for hospital

    Original Title

    Active File Audit for hospital

    Copyright

    © © All Rights Reserved

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    The document is an audit report listing missing or incomplete documentation for a patient's hospital records. It identifies 17 parameters for which documentation is either missing or incomplete, including consent forms, checklists, records from the operating room and intensive care unit. The nurse administrator is notified that documentation is missing the patient's and relative's signatures and dates in several areas, as well as other incomplete details like risk factors and languages. The audit serves to ensure all required documentation is properly completed for the patient's file.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    674 views4 pages

    Active File Audit For Hospital

    Uploaded by

    Rahul Indalkar
    The document is an audit report listing missing or incomplete documentation for a patient's hospital records. It identifies 17 parameters for which documentation is either missing or incomplete, including consent forms, checklists, records from the operating room and intensive care unit. The nurse administrator is notified that documentation is missing the patient's and relative's signatures and dates in several areas, as well as other incomplete details like risk factors and languages. The audit serves to ensure all required documentation is properly completed for the patient's file.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    You are on page 1of 4

    MRN No.

    :-
    Bed No. :-
    Adm. Date & Time :-
    Active
    ActiveFile
    FileAudit
    Audit Consultant :-

    Date:-
    TO,
    The Medical Officer/Nurse Administrator . (Unit / ICU)
    The Following Documents are Missing/Incomplete.

    Status
    Sr. [Y-Yes Page
    Parameters
    No. N-No No.
    "-" = N.A.]

    1 Consent for Hospitalization and Conditions of Service

    2 MEDICO-LEGAL CASE INTIMATION

    Consent for Anaesthesia -Reason of Anaesthesia


    3 -Type of Anaesthesia
    -Language

    Consent for Surgery -Reason of Surgery


    4 -Name of Surgery
    -Language

    -Cardiac Procedure
    5 Other Consent
    -Procedure

    -High Risk
    6 Other Consent
    -DAMA

    -HIV
    7 Other Consent
    -Blood Product

    8 Other Consent
    Pre Operative Checklist Ward Nurse
    Name Sign.
    Date Time
    9

    Pre Surgery Checklist Allocated Nurse


    Name Sign.
    Date Time
    10

    Surgical Safety Checklist OT Nurse


    Name Sign.
    11

    Anesthesia Record - Anesthesia Start Time


    12
    End Time
    OR Nursing Record Circulating Nurse
    Name Sign.
    13 Date Time

    Recovery Room Chart Data


    Not
    14 Capture

    15 ICU Chart

    16 ICU Chart

    17

    Nurse Administrator ...


    Emp. Code No. : . Dr. Rahul Indalkar (GAT00
    Electronic Medical Recor
    #N/A
    #N/A
    #N/A
    #N/A
    #N/A
    Friday, May 05, 2017

    Remark

    - Pt.'s Sign. Date & Time


    - Relative Sign. Date & Time
    - Bed & Deposit details
    - Pt.'s relative Information
    -Reason Pt. is unable to sign.

    -Pt.'s Sign Name Date


    -Doctor Sign. Name Date

    -Pt.'s Sign Name Date


    -Doctor Sign. Name Date

    Doctor Patient
    Name Sign. Name Sign.
    Date Time Date Time

    - Incomplete Details
    - Language

    Doctor Patient
    Name Sign. Name Sign.
    Date Time Date Time

    - Risk factor missing


    - Language

    Doctor Patient
    Name Sign. Name Sign.
    Date Time Date Time

    - Incomplete Details
    - Language

    Doctor Patient
    Name Sign. Name Sign.
    Date Time Date Time
    - Incomplete Details
    - Language
    OT Nurse
    Name Sign.
    Date Time

    - Incomplete Details

    Technician Anesth.
    Name Sign. Name Sign.
    Date Time Date Time

    - Incomplete Details

    Anesth. Surgeon
    Name Sign. Name Sign.

    - Doctor Name & Sign.

    Surgeon Scrub Nurse


    Name Sign. Name Sign.
    Date Time Date Time

    - Incomplete Details

    Consultant Nurse
    Name Sign. Name Sign.
    Date Time Date Time

    Doctor Patient
    Name Sign. Name Sign.
    Date Time Date Time
    - Nurse sign. after treatment
    Doctor Patient
    Name Sign. Name Sign.
    Date Time Date Time
    - Nurse sign. after treatment

    ....
    r. Rahul Indalkar (GAT00310)
    ronic Medical Record Dept.

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