REGIONAL MEMORIAL HOSPITAL INPATIENT CHECKLIST
|
|
SEARCH BY MRN#
|
SEARCH BY SS#
|
NEW RECORD
|
|
Patient First Name
|
Patient Last Name
|
Patient MRN #
|
Patient Date of Birth
|
Admission Date
|
Discharge Date
|
H&P Report Enter or Attach
|
H&P Report Completed
|
Anesthesia Report Enter or Attach
|
Anesthesia Report Completed
|
Discharge Summary Enter or Attach
|
Discharge Summary Report Completed
|
Physician Order Report Enter or Attach
|
New Yes / No
|
Consultation Report Enter or Attach
|
New Yes / No
|
Progress notes Enter or Attach
|
New Yes / No
|
Diagnostic & Lab Report Enter or Attach
|
New Yes / No
|
Inpatient Certification Enter or Attach
|
New Yes / No
|
Admission Order Enter or Attach
|
New Yes / No
|
Surgical Procedure Report Enter or Attach
|
New Yes / No
|
Medication Administration Enter or Attach
|
New Yes / No
|
Nurse's Notes Enter or Attach
|
New Yes / No
|
Ambulance Run Sheet Enter or
|
New Yes / No
|
Signed ABN/HINN
|
New Yes / No
|
Authenticated Prior to Discharge
|
New Yes / No
|
Name of beneficiary
|
Relationship to Patient
• • •
|
Physician's Electronic Signature
|
Date and Time
|
SUBMIT FORM TO BILLING
|
PRINT
|