What's Inside

This workbook provides guidance to support your Medical Records program in your ASC.

We offer suggestions for your medical records processes, as well as policies, tools and resources made available to you as a part of your membership.

As an exclusive member, you have to access to download the template policies and forms for your customization and use.

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

  • 1

    WELCOME TO YOUR MEDICAL RECORDS WORKBOOK

    • MEDICAL RECORDS WORKBOOK

    • PHYSICIAN DOCUMENTS

    • CONSENTS

    • MEDICAL RECORDS DOCUMENTATION

    • PRE-OPERATIVE DOCUMENTATION

    • INTRAOPERATIVE DOCUMENTATION

    • PACU AND POST-OPERATIVE DOCUMENTATION

    • MEDICATION DOCUMENTATION

    • SPECIMEN DOCUMENTATION

    • PHYSICIAN ORDERS

    • OTHER CONSIDERATIONS

    • MEDICAL RECORDS 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