“Forms & Requirements”
It is our job as health care providers to be responsible with patient health records and to understand the policies and procedures when handling them. It is important to be aware of and follow federal and state laws and regulations regarding patient health information and forms to protect the patient and the facility. It is also imperative to remember that the content of any medical record needs to remain the same no matter how it is stored.
The Joint Commission is an independent, non-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States (The Joint Commission, 2018). The Joint Commission standards require that a patient’s medical record contain specific data suitable to the care, treatment, and administrations given (Bowie ; Green, 2016). Since a patient’s record contains clinical/case information, demographic information, and other information, it is crucial to remember that medical records must be precisely composed, promptly completed, appropriately documented, accessible, and properly retained by health care employees (Bowie & Green, 2016). A medical record must contain all information (diagnoses, the patient’s progress, reaction to medication, etc.) from the time the patient is admitted to the time they leave and must always be legible and complete. The author/creator of each entry must be distinguished and provide either a signature, written initials, computer entry, or all of the above. The Joint Commission requires that all medical records are to be completed within 30 days following patient discharge and that they contain identification data (Bowie ; Green, 2016). It is vitally important to enter information in a patient’s record in a timely and correct manner because it ensures the continuity of care for the patient.
The forms that comprise a patient’s administrative data are the face sheet (or admission/discharge record), advance directives, informed consent, patient property form, birth certificate (copy), and death certificate (copy). The face sheet contains the patient’s identification, financial information, and clerical information (Bowie & Green, 2016). The face sheet is usually filed first because it is used the most and contains the admitting (or provisional) diagnosis and the patient’s final diagnosis. The advance directive notification form is required by the Patient Self Determination Act (PSDA) of 1990. This requires that all health care providers must inform all patients that are over 18 years old that they have the right to an advance directive (Bowie ; Green, 2016). Examples of advance directives are living wills, medical power of attorney, Do Not Resuscitate (DNR) orders, and health care proxy. The consent to treatment form is required by The Joint Commission standards and provide proof that the patient is consenting to the medical treatment being provided. Informed consent is the process of advising a patient about treatment options and other factors depending on the state’s law. Patient property forms are provided to patient’s that come into a health facility with personal belongings. This keeps a record of the items brought in with the patient and is signed by both the patient and hospital staff member. The certificate of birth is a birth record about a newborn patient and the parents (Bowie ; Green, 2016). The certificate of death holds medical information about the deceased such as their name, cause of death, time of death, and name of their doctor.
There are numerous types of consent forms. The Do Not Resuscitate (DNR) consent form is signed by a patient which prevents CPR from being performed if their breathing or heartbeat stops. A consent to admission form is signed by the patient upon admission and provides proof that the patient is consenting to receive medical treatment. A consent to release information provides patient authorization for reimbursement and other purposes.
The emergency record contains the evaluation and treatment given to a patient in a, emergency department (ED) (Bowie ; Green, 2016). The Joint Commission requires emergency department records to contain a patient’s time and means of arrival, whether the patient left against medical advice (AMA), and the conclusion at the termination of treatment (Bowie & Green, 2016). An emergency department record also contains the treatment of the patient and their assessment, the reason for disposition, and a copy of their discharge papers (Bowie, & Green, 2016). A completed discharge summary is required by The Joint Commission and must be completed by the attending physician. This document provides data for continuity of care and documents a summary of the patient’s hospitalization. This information must be timely and accurate because every second and attention to detail counts in the emergency department.
Medical forms and their requirements are extremely important in the health care industry. It is crucial for health care workers to become familiar with regulations, laws, and standards regarding health information and documentation in order to effectively treat their patients. Not only must a document be complete, but it must also be accurate. As health care providers, we are responsible for maintaining the integrity of the patient document and we must comply with the standards that involve their keeping.
The Joint Commission. (2018). About the Joint Commission. Retrieved from
Bowie, M. J. ; Green, M. A. (2016). Essentials of health information management: Principles
and practices (3rd ed.). Boston, MA: Cengage Learning.