Medical Records Refresher

Thursday, February 14, 2013 at 2:10:17 PM

Please be reminded of the following:
o Verbal orders must be signed, dated and timed within 48 hours, and may be signed off by any provider caring for that patient. Waiting until after discharge to complete these isnít appropriate.
o History and physicals need to be completed 30 days prior to the patient arrival, and updated after admission and prior to any procedure.
o Immediate post procedure notes need to be completed prior to the provider leaving the procedure area.
o Discharge summaries need to be completed for continuum of care.
o All charts need to be completed within 30 days.

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