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Initial Visit Documentation Checklist Patient name: IP number:

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Fullness of the Admission record Informed Consent Form signed by patient Signature of Doctors/ consultant Patient name on each page of the record. Chief complaint documented. Timing and intensity of complaints documented. Causation: accident, injury, and etiology documented. Details of complaint documented. Are Clinical exam findings documented ? Written radiographic findings documented and signed. Diagnostic impression documented. Is there a diagnosis in the record ? Are Diagnostic tests documented and filed? Is there a treatment plan for this condition? Treatment/services rendered documented. Health record is complete and legible. Are all details of the initial nursing assesment filled? Are all details of the physiotherapy initial assessment filled? Health insurance claims are APPROPRIATE and SUPPORTED by documented medical necessity in the record


MLC Details