ࡱ> CEB bjbj T/hh TUUUDU.EEEEE   -------$/j2L-     -EE- XEE- -\*K-E|UxR+--0.,82"20K-2K-<       --   .    2          : CABIN CREEK AND RIVERSIDE HEALTH CENTERS P.O. Box 70, Dawes, WV 25054 (304)595-5006 Subject: Medical Records Format Policy No. MR.2 Department: Medical Records Date of Original: 6-25-03 Date of Last Revision: Approval Date Page 1 of 4 General Statement of Policy: To assembly the medical record in a consistent and uniform manner and to assure that it is in chronological order according to the filing order of the medical record. Scope: This procedure applies to all clerical staff responsible for chart assembly. Procedure: Pre-assembly Procedure Completed by front desk upon arrival of patient for visit: Verification and Updates: Correct address, phone numbers (home & work), emergency contact name and phone number and payor information. If above information is unchanged, it is acceptable to initial on upper left hand corner of the Data Sheet. Replace old copies of insurance cards with new copies and initial and date. Any record that is larger than 1 inches, shall be split into volumes. If the chart contains information greater than 3 years old, the chart shall be purged. If patient has more than one hospital admission/discharge, X-Ray, procedure, lab value; put the two or more in chronological order. If there are microfilm envelopes, tape them to the inside front of the folder. Items NOT to be included in the medical record: Multiple copies of X-Rays, hospital admission/discharge reports, etc. Fax confirmations Any blank forms CABIN CREEK AND RIVERSIDE HEALTH CENTERS P.O. Box 70, Dawes, WV 25054 (304)595-5006 Subject: Medical Records Format Policy No. MR.2 Department: Medical Records Date of Original: 6-25-03 Date of Last Revision: Approval Date Page 2 of 4 Assembling Medical Record Assemble forms in chronological order according to filing order of the medical record. Assemble forms according to the order given in this policy Charts are identified with typewritten white labels with: Patient Name Date of Birth Chart is further identified with: Color coded label for most recent / current year patient was seen Color coded labels for first two (2) letters of patients last name Medical Record / Patient Chart Dividers Right side of chart Progress Notes BCCSP (Only Breast and Cervical Cancer Screening Program Patients) Signed Informed Consent Visit Note Family Planning (Only Family Planning Patients) Signed Yearly Consent Form Visit Note Counseling Form BC Consent EPSDT All child health history forms Growth charts Prenatal (Only Pregnant Patients) Hospital DC All hospital discharges including ER visits Cardiac Echocardiography results 12-Lead EKGs Stress Test Results Cardiac catherization results CABIN CREEK AND RIVERSIDE HEALTH CENTERS P.O. Box 70, Dawes, WV 25054 (304)595-5006 Subject: Medical Records Format Policy No. MR.2 Department: Medical Records Date of Original: 6-25-03 Date of Last Revision: Approval Date Page 3 of 4 Carotid Doppler Venous & / or Arterial Duplex results All other heart related Procedures PFTs, Spirometry Biopsy Op reports (colonoscopy, cholecystectomy, CABG, etc) All procedures Home Health Orders Correspondence Letters from consulting physicians Medical History (Old Records) Miscellaneous Left side of chart Green Problem List New Patient Questionnaire Health Maintenance form Medication Pink Medication Sheet Yellow Prescription copies Pink Pharmacy Refill Requests Immunization records Injectable BC form CNP Patient Acknowledgement Lab Labs PAP results Pathology reports Protime sheet CABIN CREEK AND RIVERSIDE HEALTH CENTERS P.O. Box 70, Dawes, WV 25054 (304)595-5006 Subject: Medical Records Format Policy No. MR.2 Department: Medical Records Date of Original: 6-25-03 Date of Last Revision: Approval Date Page 4 of 4 X-Rays All X-Rays Mammogram CT Scans, MRIs Ultrasound Nuclear Medicine test results IVPs DEXA scans Thyroid scans Referrals All documentation for referral of patients to outside providers Communication Orange Telephone Message / Intake Sheets Any Provider to patient communication including: Letters of Missed appointments / no shows Letters of Patient Termination HIPAA Al Consents Treatment, Release of Information & Authorization Patient Info / Billing Patient demographics CAP information Insurance information including copies of insurance cards If there is any part of the patient record that is not in the correct order, bring it to the attention of the MRT Team Leader or Record Processing Team Leader.     )TU^t     " # < w - 3 6 ] Ƚ|qe\hjZ5CJaJhjZ5>*OJQJ\hjZ>*OJQJ\hW5OJQJ\hjZhjZOJQJ\hjZOJQJ\h[hWOJQJhjZOJQJh[hW5OJQJ\hjZ5OJQJ\hjlh!5CJaJhjZ5CJaJh!5CJaJh!CJaJh!CJaJh!5CJaJ")FTU   # gd!gd! ]^gd! d ]^d&dPgd!d^`gd!dgd!d$dNgd! dgd! $da$gd!# $ ; < w Y , - ]  dgdjZ $da$gdjZ & FgdjZgdjZ & FgdjZgd! p:;мdzǼdzǧhjhUhjZhjZOJQJ\hjZ5CJaJhjZ>*OJQJ\hjZOJQJ\hjZ5OJQJ\hjlhjZ5CJaJhjZ5CJaJhjZCJaJhjZCJaJ!RS7r,op & F gdjZ & F gdjZ & FgdjZ & FgdjZgdjZd&dPgdjZd^`gdjZdgdjZd$dNgdjZ%Wr}+6O\p dgdjZ $da$gdjZ & F gdjZ  & F^gdjZRi1@SdgdjZ  & F^gdjZ & F gdjZd&dPgdjZdgdjZd$dNgdjZ1Lj,:; dgdjZ $da$gdjZ ^ gdjZ & F gdjZ & F gdjZ & F gdjZ;op 6;FT^1 & F gdjZ & F gdjZ & F gdjZd&dPgdjZd^`gdjZdgdjZd$dNgdjZ1PW dgdjZgdjZ & F gdjZ & F gdjZ & F gdjZB 00P1+:pW/ =!"#$% DpB 00P1+:pW/ =!"#$% DpB 00P1+:pW/ =!"#$% DpB 00P1+:pW/ =!"#$% DpB 00P1+:pjZ/ =!"#$% Dpf 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~OJQJ_HmH nH sH tH J`J Normal dCJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List RoR Style1$7$8$H$ CJOJQJ_HaJmH sH tH 44 jZ0Header  H$66 jZ0 Header CharCJaJ4 "4 jZ0Footer  H$616 jZ0 Footer CharCJaJPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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