What's Inside

This Resource provides a framework to support your Medical Records processes.

This toolkit is set up as a repository for all the medical record policies made available to you as a part of your membership. We have even included a "Passport" where we explain the process and steps you should take.

As an exclusive member, you are free to explore this library, access its resources and download them where we've enabled you to do so.

Here is a breakdown of what is included in this toolkit:

  • 1
    WELCOME TO YOUR TOOLKIT
    • START HERE
    • MEDICAL RECORD PASSPORT
    • PASSPORT CHECKLIST
  • 2
    POLICY LIBRARY
    • ABOUT THE LIBRARY
    • APPROVED ABBREVIATIONS
    • HISTORY AND PHYSICAL
    • INFORMED CONSENT
    • MEDICAL RECORDS POLICY
  • 3
    TOOLS
    • INFORMED CONSENT TEMPLATE
    • ANESTHESIA CONSENT TEMPLATE
    • HISTORY AND PHYSICAL TEMPLATE
    • OPERATIVE CONSENT TEMPLATE
    • PRE OPERATIVE NURSING RECORD TEMPLATE
    • DVT ASSESSMENT TEMPLATE
    • MEDICATION RECONCILIATION FORM TEMPLATE
    • ANESTHESIA RECORD TEMPLATE
    • INTRA-OPERATIVE NURSING RECORD TEMPLATE
    • PACU NURSING RECORD TEMPLATE
    • SPECIMEN LOG TEMPLATE
    • NURSING CHART AUDIT TEMPLATE
    • MEDICAL RECORDS CHECKLIST TEMPLATE
    • SAFE SURGICAL CHECKLIST TEMPLATE
  • 4
    RESOURCE LINKS
    • RESOURCE LINKS
  • 5
    TRAINING
    • COMPLIANCE TRAINING
  • 6
    ADDITIONAL SUPPORT
    • ADDITIONAL SUPPORT