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To add bookmarks
1) Make sure you are on the page you would like to bookmark.2) Click on the bookmark symbol.3) Then name the bookmark and click enter.
To view the example bookmarks click this icon.
PDF Bookmarking Instructions
Demographic Page
Include date of birth, race, ethnicity, and gender. Admission and Discharge Date
Pre-op H &PPreoperative H&P and preoperative office notesInclude 5-Meter walk if done.
Admission H&P
H&P used for the patient's admission
Hospital Progress Notes
Consult Notes
Pre-op and Post-op Lab Results
Cr, Bili, INR, and A1c if available -- Post op glucose include point of care
Home Medications and MAR
PFTs Carotid
Ultrasound Tests done prior to surgery
Misc DataOutside record and/or transfer recordsRespiratory Notes - Extubation and/or Re-intubation Times
Operative Report
All operative notes for the entire episode of care including the index surgery and returns to OR. If multiple physicians participated in the surgery, include the notes from both surgeons.
Device Info--Device Sticker
ICU Times
OR Times
Hospital Progress Notes:Progress notes from the patient's surgical admission including any notations of complications, intubation, extubations, and reintubations.
Blood Transfusions
If this is a scanned document make sure it is legible
Pre-op Intra-op Post-op
Echo
Consult Notes:Consult notes from the patient's surgical admission including any notations of complications.
Cath Lab Report
Perfusion Form
If this is a scanned document make sure it is legible
Discharge Summary
Anesthesia:Anesthesia report that includes the patient's disposition from the OR
Procedure Times:
Include documentation that provides the procedure start and end times.
Outside Records -Clinic Records
Discharge Status:
Discharge Summary for the episode of care
30 Day Follow Up
Medical or surgical dictation, office notes, or screen shot of encounters. Documentation of any follow up encounter the patient had after discharged greater than or equal to 30 days
Readmission Data