CHART ORDER LIST
CHART ORDER LIST
CHART ORDER LIST
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<strong>CHART</strong> <strong>ORDER</strong> <strong>LIST</strong><br />
Revised 2003<br />
Administration<br />
J2020 Disclosure Tracking Log (on the left side under administration)<br />
H003 Patient Registration<br />
H151 OB Discharge Summary<br />
J629 Newborn Discharge Summary<br />
Discharge Summary<br />
H128 Authorization & Agreement<br />
J1110 Receipt of Notice of Privacy Practices<br />
J610 Important Notice A,B,C<br />
H341 Discharge Prescription<br />
J983 Secondary Prevent<br />
J439 Flight Record<br />
J440 Physician’s Certificate for Transport<br />
J1070 Transfer Agreement<br />
J076 Inter-Facility Transfer Form<br />
J100 Record of Possession of Medico-Legal Substances<br />
H101 Record of Examination-Alleged Rape<br />
J453 Report of Suspected Adult Abuse/Neglect<br />
H889 Report of Suspected Child Abuse/Neglect<br />
J987 Pre-Discharge Evaluation of Risk to Self and Others<br />
J635a Discharge Instructions<br />
J635s Discharge Instructions (Spanish)<br />
H646 NICU Discharge Instructions<br />
J677 Medication Information<br />
J686 Endoscopy Discharge Instructions<br />
J588 Autopsy Report<br />
Master Treatment Plan Attendance Record<br />
Master Treatment Plan Nursing Care Record<br />
HISTORY & PHYSICAL/CONSULTS<br />
J492 ED History & Physical<br />
ED Attending Note<br />
J679 Maxillofacial Trauma Evaluation<br />
J499 Trauma Admission<br />
J900 Spine Clearance<br />
J961a-f Orthopaedic Surgery H&P<br />
J441 Labor & Delivery Summary<br />
H076 Short Stay Re-Admission Record<br />
J698 Obstetric History & Physical<br />
J908 Labor Progress Record<br />
H315 Consultation Request<br />
H336 Psychological Evaluation<br />
J669 Psychosocial Assessment<br />
J671 Initial Social Work Assessment<br />
J683 Retinopathy of Prematurity Consultation<br />
J203 Medical Consultation<br />
J628 Newborn Admission<br />
J1060 1-4 2, 3, & 4 Neonatal/Pediatric Transport H&P Transport Record<br />
J1057 Neonatal Intensive Care Unit Progress Note<br />
J975 Neonatal Intensive Care Resident H&P<br />
J912 Children’s Hospital Admit Note<br />
H291 History/Physical/Progress Notes<br />
D601 Child Life Progress Note – date order<br />
J1005 Procedure Form (filed in date order w/progress notes)<br />
J288 Progress Notes<br />
J690B Psychiatric Night Shift Nursing Progress Report<br />
UKPHO Pediatric Hematology-Oncology Daily Care Note – date order in Progress Notes<br />
Neonatal Intensive Care Unit Discharge Evaluation<br />
J236 CPR Record-Code 500<br />
J236a Pediatric Code Sheet 500<br />
J1096 Supportive Oncology Services (S.O.S) Screening Instrument<br />
J2006 Post-operative/Progress Notes<br />
OR RECORD (in date order of procedures)<br />
J807 Blue History & Physical<br />
H445 Green Pre-Operative Checklist<br />
Site Verification Checklist<br />
H299 Anesthesia Record<br />
H245 Anesthesia Record Continuation Sheet<br />
H354 Anesthesia Record<br />
H345 Anesthesia Record Continuation Sheet<br />
J821 Labor Epidural Analgesia Record<br />
H720 Operative Procedures Notes<br />
H425 OR Patient Record<br />
Operative Report<br />
Brief OP Note<br />
H488 Surgical Pathology Report<br />
J400 Perioperative Nursing Record<br />
J1022 PACU Flowsheet<br />
J384 PACU Flowsheet<br />
J407 OB Recovery Room Sheet<br />
J694 Gamma Knife Flowsheet<br />
J176 Clinical Record Fibroptic Bronchoscopy<br />
H742 Endoscopy Diagrams –Upper GI Tract<br />
H743 Colonoscopy Results<br />
Endoscopy Report<br />
J490 Endoscopy Lab Flowsheet<br />
D300 Manometry/ph Monitoring<br />
J910 Diagnostic Radiology Flowsheet<br />
H455 Cardiopulmonary Perfusion Record<br />
J661 Invasive Cardiology/Electrophysiology Report<br />
J514 Cardiac Cath Patient Report<br />
Cardiac Cath Report<br />
J981-1 Electrophysiology Serv. Nursing Flowsheet<br />
J981-2 Electrophysiology Serv. Nursing Flowsheet Cont.<br />
J660 Cardiology Procedure Report<br />
J840 Electrophysiology Pacer Record<br />
* ALL PHYSICIAN’S <strong>ORDER</strong>S FILE IN DATE <strong>ORDER</strong> *<br />
J337 Infant Delivery Record<br />
J488 ED Physician’s Trauma Orders<br />
J732 ED Chest Pain<br />
Acute Myocardial Infaraction Phy/Pt care orders<br />
H310 Physician’s Orders<br />
To Be Put in Date Order:<br />
H310E Physician’s Orders – date order<br />
H310H Physician’s Orders – date order<br />
University Physician/Patient Care orders<br />
Acute Ischemic Stroke Admission Orders<br />
H657 Standing Orders for Initial Tx<br />
J426 Adult TPN Physician’s Orders<br />
J428 Pediatric Neonatal TPN Physician’s Orders<br />
J443 Chemotherapy Orders<br />
J519 Antimicrobial Orders<br />
J529 Chromosome Analysis-Genetic/Prenatal Orders<br />
J530 Chromosome Analysis-Oncology Orders<br />
J569 Respiratory Therapy Order Sheet<br />
J621 Anti-Endotoxin Monoclonal Antibody Order<br />
J701 Epidural Physician’s Order<br />
J705 Peripheral Nerve Block Patient Controlled Analgesia<br />
J706 IV Patient Controlled Analgesia Physician/Patient Care Orders<br />
J707 NICU Admission Physician/Patient Care Orders<br />
J729 Postoperative Anesthesia Physician/Patient Care Orders<br />
J994<br />
J510 Vascular Laboratory Examination<br />
J1015 Echocardiogram Request<br />
H330 83 Pulmonary Function Requisition<br />
J0002 Non-Gynecologic Cytopathology<br />
H489 Gynecologic Cytopathology<br />
J997 Alcohol Dep Protocol<br />
J998 Polydrug Dep<br />
CX01 Signature Record<br />
Critical Pathways
EKG (and other special test)<br />
EKG Reports<br />
J008 EKG Strips<br />
Echocardiography Report<br />
J282 Adult Echo Report<br />
J527 Adult Echo Report<br />
Transesophageal Echocardiography Flow Sheet (blue)<br />
J536 Transesophageal Echo Monitoring Report<br />
J397 Stress Test Report<br />
Holter Monitoring Report<br />
To be put in date order:<br />
H312 EEG Report<br />
Electromyography<br />
J319 NCV Nerve Conduction Velocity<br />
J344 Bone Marrow Processing forms<br />
J429 Adult Bone Mineral Density<br />
J430 Pediatric Bone Mineral Density<br />
J566 Evoked Potential Report<br />
Multi-channel Sleep Recording Report<br />
J401 Sleep Study Report<br />
J664 Cardiopulmonary Exercise Test Report<br />
OB High Risk form<br />
Antepartum Testing<br />
Respiratory/ Rehabilitation<br />
J817 Initial Evaluation<br />
J070 Resp. Therapy Tx Record<br />
J089 Resp. Therapy Ventilator Record<br />
J316 Pediatric Ventilator Record<br />
J541 BiPap S/T Record<br />
H331 Spirometry & Lung Volume<br />
H538 Rehabilitation Progress Notes<br />
H789 Asses. Plan of Care & Progress Notes<br />
J959 Gait Training<br />
J952(1&2) Splint Evaluation<br />
J474 Respiratory Care Services Metabolic Study<br />
D912 Bronchial Hygiene Evaluation<br />
H330 Pulmonary Function Test<br />
J321 Pulmonary Function Studies<br />
Pulmonary Function Report<br />
J432 Hyperbaric Oxygen Therapy H&P Screen<br />
J433 Record of Hyperbaric Treatment Exposure<br />
J955 Physical Therapy Cardiac Evaluation<br />
J951 Cardio Pulmonary/Transplant Evaluation<br />
J395 Rec. Therapy Initial Assess. & Activity Evaluation<br />
J667 Occupational Therapy Evaluation<br />
Radiology/Radiation/Nuclear Medicine<br />
Radiology Reports<br />
J264 Radiology Special Procedures<br />
J408 Duplex Ultrasound Cerebrovascular Exam<br />
J172 Tx/Implant Summary<br />
Radiation Implant Summary<br />
Laboratory<br />
Laboratory Report papers (originals)<br />
Outside labs (outside referrals)<br />
PKU results (stick on another sheet)<br />
Hemodialysis<br />
D350 Hemofiltation Flow Sheet<br />
J425 Peritoneal Dialysis<br />
Continuous Renal Replacement Therapy<br />
J125 Drug Monitoring<br />
To be put in form # order H before J<br />
H249 Virology<br />
H489 Cytopathology Consultation<br />
H031 Coagulation<br />
H035 Bacteriology<br />
J326 Histopathology<br />
J339 Drugs of Abuse Screen<br />
J349 Serology Requisition (if HIV + only)<br />
J496 Cytogenetics Report<br />
J497 Molecular Diagnostic Lab report<br />
J498 Flow cytometry Lab<br />
J532 Laboratory Consultation<br />
J579 Cytopathology Report (file w/surgery if matches date)<br />
Vascular Lab<br />
Nursing Notes<br />
J599 ED Nursing Care Record<br />
J491 ED Nursing Care Record Continuation<br />
Level of Care Scoring System<br />
J494 Trauma/Critical Care Nursing Record<br />
J491 Trauma/Critical Care Nursing Record Cont.<br />
J372 Nursing Neonatal Transport Flowsheet<br />
J521 23 Hour Admission Record<br />
J538 Pediatric 23 Hour Admission Record<br />
J015 Nursing Data Base/Shift events update (All except for Psych)<br />
J1046 Pt Care Observation/Assessment*<br />
J011 Neonatal ICU Nursing History<br />
J014 Nursing Care Plan (Kardex)<br />
J445 Patient Care Plan Continuation<br />
J597 PACU Standard Care Plan<br />
J806 PACU Acuity<br />
J690 Patient Care Plan<br />
J691 a,b,c Patent Care Plan Continuation<br />
J695 Diagnostic Imaging Nursing Notes<br />
J520 Psychiatry nursing Rounds<br />
J687 Nursing Group Notes –Psychiatry<br />
J1025 Inpt. Psychiatry Group Therapy Notes<br />
J092 Neurological Flowsheet<br />
J332 Neurovascular Assessment<br />
J368 Transitional Nursery Flowsheet<br />
J292 Patient Care Record<br />
H962 Pediatric Patient Care Record<br />
J005 Burn Unit Nursing Notes<br />
J006 Estimation of Size of Burn by Percent<br />
J391 Nursing Evaluation<br />
J462 Nursing Initial Shift Assessment<br />
J335 Antepartal Nursing Discharge Summary<br />
J336 OB/Newborn Nursing Discharge Summary<br />
J241 Pediatric Patient Summary<br />
Teaching Sheet<br />
J1078 Interdisciplinary Patient/Family Education<br />
H440 Home Health<br />
Medication Records<br />
J359 Pain Management Medication Record<br />
J386 Notice of Sedation<br />
J1003 A&B Ped, Critical Care & Sedation Service<br />
Frequent Assessment Monitoring Records<br />
J525 PCS Paper (medication sheet)<br />
J1099 Pain Assessment Management Flow Sheet<br />
J359 Pain Management PCA Flow Sheet<br />
J962 Amin. & Vanc. Pharmacokinetic Monitoring<br />
Graphics<br />
J110 Emergency Transfusion Request & Release<br />
ED Transfusion Record<br />
H964 Blood Bank Transfusion Reaction<br />
H288 Transfusion Reaction Report<br />
J485 Vital Signs Flowsheets<br />
J486 Intake/Output Flowsheets<br />
J071 Intake Flowsheet<br />
J696 ECMO Laboratory Flowsheet<br />
J697 ECMO Flowsheet<br />
ECMO Shift<br />
CT ICU Flowsheet<br />
J475 Initial Nutrition Assessment<br />
J483 Nutritional Flow Sheet<br />
J009 Sedative Hypnotic Withdrawal Sticker<br />
J115 OPIOD Drug Withdrawal<br />
H152 Labor Flowsheet<br />
H959 Special Fluid Balance Record<br />
H960 Newborn Data Flowsheet<br />
H961 Special Clinical Nurses Record<br />
J221 Seizure Flowsheet<br />
J261 Pediatric ICU Flowsheet<br />
J262 Pediatric ICU Flowsheet<br />
J905 PT. Event Record<br />
D255 Initial Phy Assess. For Behavioral Health Care<br />
J518 Restraint Flowsheet<br />
Authorizations<br />
H318 Authorization for Special Procedures<br />
WOO4 Request for Restrictions Regarding Treatment, Payment and Health Care Operations<br />
J1101 Consent for Treatment of Cancer with Chemotherapy<br />
H321 Authorization for Autopsy<br />
H322 Authorization for Leaving the Hospital AMA<br />
H324 Authorization for Therapeutic Abortion<br />
H326 Authorization for Disposal<br />
H328 Authorization to Take Photographs<br />
H357 Authorization for Removal of Anatomical Gifts<br />
Consent for Bereavement Services<br />
H906 Bequeathal of Body<br />
J127 Authorization for Neonatal Transport<br />
J299 Perinatal Sibling Visitation Record<br />
J427 Auth. to Allow Others to Interact with Infant/Child<br />
J431 Auth. For Release of Birth Announc. To the Media<br />
J436 Temporary Release form the Hospital<br />
J438 Reverse Transport Agreement<br />
J468 Hepatitis B Vaccine<br />
J489 Voluntary Consent to Hepatitis B Vaccine<br />
J559 Newborn Screen Informed Release<br />
J602 Vaccine Consent<br />
Rejection of Blood Transfusion<br />
LB146 Newborn Maturity Rating and Classification<br />
Weight Chart<br />
J567 Premature Infant Growth Chart<br />
Valuables Release<br />
Newborn Identification Record (foot)<br />
Birth Certificate (all four forms)<br />
Hearing Risk Screen<br />
Death Certificate (all three forms)
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