Medical Records Checklist

Discharge Summary
EMS Run Sheet
Emergency Room Record
Admission History and Physical
Progress Notes
Physician’s Orders
Physician’s Consult Report
Medication Admission Records
IV Flowsheets
-Administration may be documented on a flowsheet or encompassed in the MAR
Laboratory results
Radiology/Diagnostic testing
-Including X-rays, CAT scans, MRIs, EKGs, EEGs, etc.
Nursing Flowsheets
-Should include vital signs, intake and output, assessment data, treatments, and comments
Nurse’s Notes
-Are sometimes encompassed in the flowsheets. May have an “Interdisciplinary notes” section that includes non-physician notes
Nursing Admission History and Assessment
-Initial skin assessment for presence of pressure ulcer is found here-it is a Joint Commission Requirement to document absence/presence of a pressure sore on admission.
Restraint Flowsheet and Orders
Respiratory Therapy
-Especially if patient was intubated or experienced a respiratory event
-There may be ventilator flowsheets
Nutrition Assessments/Consults/Flowsheets
Occupational Therapy
Physical Therapy
Speech Therapy
-Especially important in strokes and traumas
-Swallow studies are done by speech therapy
Wound care documentation
-May have separate section, or be encompassed in Progress Notes
Consents
DNR orders
Operative Section
-Includes preop, intraop, and postop information, Anesthesia documentation, OR reports, PACU Flowsheets
CPR record (Code Sheet)
Rapid Response/Critical Assessment Team Record
Diabetic Flowsheets
-Are used any time patient is on blood sugar checks, whether diabetic or not
Hemodialysis Flowsheets
Stroke Scale
Discharge Flowsheet/Checklist
Electronic Fetal Monitoring Strips
Delivery Record
-Includes pertinent maternal, delivery, and neonatal resuscitation information
Death Certificate
Autopsy Report
Nursing Home
-Care conferences, Skin care, Bladder retraining, etc.
Physicians office visits
Outpatient Therapies
Outpatient Treatments (Steroid injections, etc.)