CHECKLIST FOR AUDIT OF SEHAT INSAF PATIENT FILES

CARDIAC SURGERY
Sr. Documents Present Absent Remarks
No.
1 Admission Form
2 History Sheet
3 CNIC
Nursing
4 Vital Signs
5 ECG
6 Fluid Balance Sheet
7 Nursing Handing Over sheet
8 Patient Management Sheet (Nursing)
9 Nursing Notes
Consent Forms
10 General Consent Form
11 Anesthesia Consent Form
12 Anesthesia PreOp Assessment
13 Anesthseia Record Form
14 Recovery Area Form
15 Surgical Consent Form
16 Blood transfusion Consent form
(if applicable)
17 High risk Consent Form
18 Consent Form in Urdu
Surgery
19 Surgical Safety Checklist
20 Operation Notes
21 Perfusion Record
Clinicial Care
22 Doctors Notes (MO/Consultantant/SR)
23 Patient Management Sheet (Clinical)
24 Drug Medication Sheet
25 Clinical Pharmacist Review Sheet
(If applicable)
Others
26 Lab Reports
27 Discharge Summary
28 Discharge Instruction
29 Follow up
30 Disposable Items Checklist
31 Final Bill
 CHECKLIST FOR AUDIT OF SEHAT INSAF PATIENT FILES
CATH LAB
Sr. Documents Present Absent Remarks
No.
1 Admission Form
2 History Sheet
3 CNIC
Nursing
4 Vital Signs
5 ECG
6 Fluid Balance Sheet
7 Nursing Handing Over Sheet
8 Patient Management Sheet (Nursing)
9 Nursing Notes
Consent Forms
10 General Consent Form
11 Procedure Consent (Angiography/
Angioplasty)
12 Consent Form in Urdu
13 High Risk Consent Form
Cath Procedure
14 Pre-Cath Checklist
15 Cath Lab Checklist
16 Preliminary/progress report
17 Post-Procedure Reports
Clinical Care
18 Doctors Notes (MO,/Consultantant/SR)
19 Patient Management Sheet (Clinical)
20 Drug Medication Sheet
Others
21 Lab Reports
22 Discharge Summary
23 Discharge Instruction
24 Follow up
25 Disposable Items Checklist
26 Final Bill
27 CD Documentation