Patient Medical Record checklist

Electronic Medical Details
Is the pathology labelled / filed properly?
Is labelling done properly for Diagnostic Imaging?
Are electronic letters done for correct patient?
Are scanned documents done for correct patient?
Are the electronic letters FORWARDED?
Are the electronic letters SENT BACK?
Are the electronic letters DISTRIBUTED?
General details
Mention the Medical Record Number
Manual Medical Record Check
Is the Patient Label done on all ALL Consultation Report pages?
Are Correspondence of correct patient done?
Are the results done accurately?
Are the labels of the patient done properly?
Is the medical record file / cover well maintained?
Are the recent documents placed on top?
Are there separate tab for every documents?
PATIENT REGISTRATION SCREEN Checks
Is General Practitioner available on Patient Registration Screen?
Is the marital status updated on Patient Registration Screen?
Is the title updated on Patient Registration Screen?
Is Next of Kin updated?
Did Referral Screen have Copy to Doctors option?
In Patient Registration Screen was "Estate of" marked incase of Deceased?
Is Date of Death written incase of Deceased?
In Patient Registration Screen was "deceased" marked incase of Deceased?

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