Healthcare

Accreditation Council for Pharmacy Education (ACPE) Program Records

No description.

Accreditation Council for Pharmacy Education (ACPE) Program Records

No description.

Acohol Monthly Usage Reports

No description.

Adverse Drug Reaction Reports

Reports to the Food and Drug Administration (FDA) describing adverse drug reaction.

Adverse Drug Reaction Reports

Reports to the Food and Drug Administration (FDA) describing adverse drug reaction.

Alcohol Monthly Usage Reports

No description.

Alcohol Perpetual Inventory Records

No description.

Alcohol Perpetual Inventory Reports

No description.

Annual and Semi-Annual Drug Inventory Report

No description.

Annual and Semi-Annual Drug Inventory Reports

No description.

Autopsy Blocks

No description.

Autopsy Reports

Records that document the listing results on laboratory analyses on an autopsy. Original report should be transferred to patient file.

Autopsy Slides

No description.

Birth Certificate

Original certificate is issued and maintained by the state. Records that document vital birth records and certificates filed with state registrar of vital statistics. Records may include any birth record, or amendments thereto, in certificate form or in report form as collected by the county health officer.

Birth Registers

No description.

Blood Bank Records

Testing Records Blood Donor Records Blood Transfusion Records (Blood Bank) (I would recommend the following description: Records that document records maintained in a blood bank which record the donor information, storage and distribution of the product, compatibility testing, quality control records, transfusion reaction reports and complaints, and general records. Records may include the logs which indicate on-hand inventory and notices of emergency shortages. General records are described as records of the sterilization of supplies and reagents, responsible personnel, errors and accidents, maintenance of equipment and the physical plant, and the expiration dates of supplies and reagents. Quality control records include: calibration and standardization of equipment, performance checks, periodic check of sterile technique, and periodic tests of the capacity of shipping containers to maintain the proper temperature. Compatibility tests include the results of cross-matching, antibody screenings, and the results of confirmation testing. Storage and distribution records include: the distribution and disposition of the blood product; visual inspection of whole blood and red blood cells during storage and immediately before distribution; storage temperature control and initialed temperature log or recorder chart; and emergency releases of blood including a physician's signature. Donor records include: donor selection , informed consent, medical interview and examination, permanent and temporary deferrals, donor adverse reaction complaints and reports, investigation and follow-up, therapeutic bleedings, immunization, and blood collection including phlebotomist's name.

Blood Bank Requisitions

No description.

Blood Gas Report

No description.

Body Film Badge Records

No description.

Borrow and Loan Records

No description.

Controlled Substances Dispensed

No description.

Controlled Substances Purchases and Distribution

No description.

Credentialing Files

No description.

Cytology Reports

No description.

Death Certificate

Records that document the death of a patient. The record (master) copy should be filed with state vital statistics office or county health officer. The duplicate should be filed in the patient's medical file.

Death Register

No description.

Delivery Room Registers

No description.

Discharge Registers

No description.

Disposition of Radiopharmaceuticals

No description.

Donor/Recipient Worksheets and Records

Blood Bank, Apheresis Center, HPC Stem Cell Lab.

Drug Inventory: Dangerous Drugs

This series documents the order, procurement, use, inventory, and disposition of dangerous drugs for use in research and teaching. This series may include, but is not limited to: order logs, receipts, use logs, and disposition instructions.

Drug Item Analysis Reports

Reports include departmental (micro) and wholesaler.

Drug Purchase Orders (Non-Controlled)

No description.

Emergency Department Logs

No description.

Emergency Room Records

No description.

EML Outreach Records

No description.

Equipment Inspections

No description.

Errors in Test Results

No description.

Exposure Records

No description.

Fetal Monitors

No description.

Final Testing Reports

No description.

Floor Inspection Records

No description.

Free Floor Stock Insurance Records

No description.

Histopathology Tissue Pathology Reports and Slides

See laboratory reports.

Immunohematology Reports

No description.

Inpatient Medication Discharge Profiles and Billing Records

No description.

Instrument Printout Reports

No description.

Kodachromes

No description.

Manual Worksheets

Records may include absorbance readings, observations, calculations, graphs, and other related records.

Master Patient Index

No description.

Medical Records (Adult Patients)

Records that document the current and complete medical record for every patient seeking care or service from an Emory healthcare provider or facility, including dental care and mental health and drug addiction counseling, multiphase clinics, hospitals, medical/nursing schools, EMS providers, and limited care residential facilities. The medical record shall contain information required for the completion of a birth, death, or stillbirth certificate and may contain the following information: identification data; chief complaint or reason for seeking care; present illness; personal and family medical history; physical examination report; provisional and pre-operative diagnosis; clinical laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; requisitions for laboratory tests; medical and surgical treatment notes and reports; evidence of appropriate informed consent; evidence of medication and dosage administered; tissue reports; physician, nurse, and therapist progress notes and reports; principal and secondary diagnoses and procedures when applicable; discharge summary; appropriate social services reports; autopsy findings; individualized treatment plans; clinical assessments of patient's needs; certification of transfer of patient between facilities; routine inquiry form regarding organ donation in the event of death; operative reports and progress notes; postoperative information; referral sources; intake interviews; orientation program documentation; mental status examination and assessments; documentation of seclusion and restraints usage; physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; when applicable, Department of Health or Children and Families’ forms for the reporting of child, elder, or domestic violence and trauma reports; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on a medical device transplant; bone marrow test reports; dialysis records; diet counseling and restriction notations; interpretations of the EEG, EKG, and fetal heart monitor tracings or if no tracings are reported - the actual tracings are included; infant screening test reports; nuclear medicine reports; x-ray interpretation records; growth charts and allergy history; emergency care rendered prior to arrival at the facility; time police or medical examiner notified; infection notices and follow-up; security notices for violent or unstable patients and accompanying family members; and adverse incident reports. Additional items may be included in the patient medical file on a case by case basis and under the recommendation of a professional or medical standards organization.

Medical Records (Minor Patients)

Records that document the current and complete medical record for every patient seeking care or service from an Emory healthcare provider or facility, including dental care and mental health and drug addiction counseling, multiphase clinics, hospitals, medical/nursing schools, EMS providers, and limited care residential facilities. The medical record shall contain information required for the completion of a birth, death, or stillbirth certificate and may contain the following information: identification data; chief complaint or reason for seeking care; present illness; personal and family medical history; physical examination report; provisional and pre-operative diagnosis; clinical laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; requisitions for laboratory tests; medical and surgical treatment notes and reports; evidence of appropriate informed consent; evidence of medication and dosage administered; tissue reports; physician, nurse, and therapist progress notes and reports; principal and secondary diagnoses and procedures when applicable; discharge summary; appropriate social services reports; autopsy findings; individualized treatment plans; clinical assessments of patient's needs; certification of transfer of patient between facilities; routine inquiry form regarding organ donation in the event of death; operative reports and progress notes; postoperative information; referral sources; intake interviews; orientation program documentation; mental status examination and assessments; documentation of seclusion and restraints usage; physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; when applicable, Department of Health or Children and Families’ forms for the reporting of child, elder, or domestic violence and trauma reports; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on a medical device transplant; bone marrow test reports; dialysis records; diet counseling and restriction notations; interpretations of the EEG, EKG, and fetal heart monitor tracings or if no tracings are reported - the actual tracings are included; infant screening test reports; nuclear medicine reports; x-ray interpretation records; growth charts and allergy history; emergency care rendered prior to arrival at the facility; time police or medical examiner notified; infection notices and follow-up; security notices for violent or unstable patients and accompanying family members; and adverse incident reports. Additional items may be included in the patient medical file on a case by case basis and under the recommendation of a professional or medical standards organization.

Medical Records Indices

No description.

Medication Error Reports

Records that document the administration of an incorrect medicatin or dose. File may include pertinent chronological information, appropriate health care facility records, and investigative reports including the identity of individual(s) responsible.

Medication Record

No description.

Monthly Internal Inspection Reports

No description.

Narcotic Records

No description.

Narcotics (Controlled Substances) Inventory

No description.

Night Cabinets/Emergency Kits Inventory & Related Records

No description.

Obsolete Inventory Records

No description.

On-Call and Staff Schedules

No description.

Operating Room Cassette Records

No description.

Operating Room Logs

No description.

Operating Room Records and Charge Sheets

No description.

Operating Room Schedules

No description.

Order for Schedule I or II Controlled Substances (DEA Form 222)

No description.

Organ Donation Logs

No description.

Outpatient Cash Report

No description.

Outpatient Prescriptions

No description.

Partially Filled Prescription for Schedule II Controlled Substances

No description.

Patient Admission Records

No description.

Patient Advance Beneficiary Notices

No description.

Patient Logs

No description.

Patient Profile

No description.

Patient Registration

No description.

Patient Testing Records and Instrument Printouts

No description.

Pharmacy Quality Assurance

No description.

Pharmacy Record Book

No description.

Photography Negatives

No description.

Photography Prints

No description.

Physician Requisitions

No description.

Physician Signature List

No description.

Productivity Monitoring Study Reports

No description.

Proficiency Testing

No description.

Proof of Use Records

Records may include Controlled Substance Dispensing Records (Non-Pyxis), Controlled Substance Dispensing (Pyxis), Anesthesia CDAR and CDM, Discrepancy/Incident reports, Pyxis Par Level reports, Controlled Substance Batch Manufacturing, PCA Dispensing, Schedule II Orals, Schedule II Injectables, Controlled Substance Infusion, Inventories, Drug Purchase Orders, and other related records.

Pulmonary Function Test

Records that document the requesting, completion, and evaluation of pulmonary function tests.

Pump Records

No description.

QA/DUE Raw Data and Reports

No description.

Quality Control Records

No description.

Radiation Dose Records

No description.

Radioisotope Records

Records that document advertisements used in the media fields of radio and television for the promotion of Emory healthcare system.

Recall Records

No description.

Refrigerator Temperature Records

No description.

Registers of Test Logbooks

No description.

Registry of Surgical Procedures

No description.

Reports of Overexposure

No description.

Requests for Tests

No description.

Sale of Schedule V Substances Without a Prescription

No description.

Signature Logs

No description.

Social Services Case Histories

No description.

Specimen Blocks

No description.

Specimen Records

No description.

Standard Ward Inventory Records

No description.

State and Federal Inspection Reports

No description.

Sterilization Records

No description.

Surgical Slides

No description.

Transfer Records

No description.

Tumor Registry

No description.

Utilization Records

No description.

X-Ray Films

No description.