HIM form question

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Reply Tue 28 Apr, 2009 08:14 am
HIM form question
I'm looking over the forms in my mothers records. Can someone tell me what foms are required in the chart when someone is first admitted?
 
TammySue
 
Reply Mon 11 May, 2009 03:39 pm
Re: HIM form question
mickey wrote:
I'm looking over the forms in my mothers records. Can someone tell me what foms are required in the chart when someone is first admitted?


it depends on the institution's policies. where i have worked (i assume you are looking at hospital records) we gathered about 8 pages of info on every patient. vital signs, name, birthdate, reason for admission, a full assessment of physical and mental condition, how to contact relatives, nutritional info, medication list, allergies, and initial orders from the doctor. there may be more, but that's what i remember off the top of my head.
 
 

 
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