Kyle Seale Parkway Ambulatory Surgery Center

Medical Records

05 MEDICAL RECORDS COORDINATOR

• 05.1 Medical Records Coordinator

10 CLINICAL RECORD MANAGEMENT

• 10.2 Clinical Record Management

15 MEDICAL HISTORY AND PHYSICAL

• 15.7 Medical History and Physical

20 AMBULATORY SURGERY RECORDS

• 20.3 Ambulatory Surgery Records

25 SUMMARY OF PROCEDURES

• 25.1 Summary of Procedures

30 MEDICAL RECORD CONTENT

• 30.6 Medical Record Content

40 ORDER OF MEDICAL RECORDS CONTENT

• 40.1 Order of Medical Records Content

50 ENTRIES IN MEDICAL RECORD

• 50.1 Entries in Medical Record

60 VERBAL ORDERS

• 60.3 Verbal Orders

80 INAPPROPRIATE COMMENTS IN THE MEDICAL RECORD

• 80 Inappropriate Comments in the Medical Record

90 ABBREVIATIONS

• 90 Abbreviations

100 PATIENT RECORD FLOW

• 100 Patient Record Flow

110 REPORT OF THE PROCEDURE

• 110.1 Report of the Procedure

120 AUTHENTICATION OF MEDICAL RECORD ENTRIES

• 120.2 Authentication of Medical Record Entries

130 REVIEWING CHARTS OF COMPLETENESS

• 130.2 Reviewing Charts of Completeness

140 CONTROL OF CHART INFORMATION

• 140 Control of Chart Information

160 RETENTION AND DESTRUCTION OF MEDICAL RECORDS

• 160.1 Retention and Destruction of Medical Records

300 POST PROCEDURE PHONE CALL

• 300M Post Procedure Phone Call