MMC MEDICAL RECORDS CHECKLIST

ADMISSION AND DISCHARGE RECORD [

]
Patients name [ ] MR#[ ] Address [
]
Demographic data: complete [ ]
incomplete [ ]
D. admission [ ] D. discharge [ ]
Admitting officer [ ] Admitted DX [ ]
Final DX [ ]
ICD Code [ ] Disposition [ ]
P.E Record [ ]
History of present illness [ ] General
survey [ ]
V/S [
] Personal History [
] Past
Medical History [ ]
Review of systems [ ] Family history [
]
Consent Form [ ]
Signed Consent to Care [
]
Date
Signed [ ]
DAMA [ ] Signed Acknowledgement of
Responsibility [ ] Date [ ]
Laboratory Results [ ]
Complete [ ] Incomplete [ ]
Doctors Orders Sheet [ ]
Date [ ] Time [ ] Doctors Signature [
]
Date & Time noted [ ] R.N Signature [
]
Progress Notes [ ]
Date [ ] Time [ ] Doctors Signature [
]
Discharge summary [ ]
Date Admitted [ ] Date Discharge [ ]
Attending Physician [ ]Admitting DX [
] Final DX [ ] C/C [ ] Brief Clinical
History &Pertinent P.E [ ]
Lab. Findings [ ] Course in the Ward [
]
Disposition [ ] Date Accomplished [ ]
R.O.D sign [ ]
TPR Sheet [ ]
Date [ ] NHD [ ] complete TPR graph [
] B.P [ ]
Wt. [ ]Urine [ ] Stool [ ] NOD sign [
]
Intravenous Sheet [ ]
Date [ ] Bot.# [ ] Kind of Soln. [ ]
Drop/ Drip Factor [ ]Time Started [ ]
Volume [ ] Nurse Sig. [ ]
Medication Sheet [ ]
Date [ ] NHD [ ] Medications : Generic
Name [ ]
Brand Name [ ] Frequency [ ] Dose
[ ]
Time Element [ ] NOD sign [ ]
Nurses Notes [ ]
Date [ ] Shift [ ] Time [ ] Diet [ ]
NOD sign [ ]
M.R. Checklist Date Accomplished:
______________
Signature of Personnel In-charge:
_______________

Note: Each page of the Medical Record must

have complete patients name, date admitted,
sex, and age. All spaces must be filled up
correctly. No erasures please. But if you made a
wrong entry do not use correction fluid to erase
it rather make a single line over the wrong entry,
write the correct entry above it and sign.
Thank you. The MR Management.

MMC MEDICAL RECORDS CHECKLIST

ADMISSION AND DISCHARGE RECORD [

]
Patients name [ ] MR#[ ] Address [
]
Demographic data: complete [ ]
incomplete [ ]
D. admission [ ] D. discharge [ ]
Admitting officer [ ] Admitted DX [ ]
Final DX [ ]
ICD Code [ ] Disposition [ ]
P.E Record [ ]
History of present illness [ ] General
survey [ ]
V/S [
] Personal History [
] Past
Medical History [ ]
Review of systems [ ] Family history [
]
Consent Form [ ]
Signed Consent to Care [
]
Date
Signed [ ]
DAMA [ ] Signed Acknowledgement of
Responsibility [ ] Date [ ]
Laboratory Results [ ]
Complete [ ] Incomplete [ ]
Doctors Orders Sheet [ ]
Date [ ] Time [ ] Doctors Signature [
]
Date & Time noted [ ] R.N Signature [
]
Progress Notes [ ]
Date [ ] Time [ ] Doctors Signature [
]
Discharge summary [ ]
Date Admitted [ ] Date Discharge [ ]
Attending Physician [ ]Admitting DX [
] Final DX [ ] C/ [ ] Brief Clinical
History &Pertinent P.E [ ] Lab.
Findings [ ] Course in the Ward [ ]
Disposition [ ] Date Accomplished [ ]
R.O.D sign [ ]
TPR Sheet [ ]
Date [ ] NHD [ ] complete TPR graph [
] B.P [ ]
Wt. [ ]Urine [ ] Stool [ ] NOD sign
[ ]
Intravenous Sheet [ ]
Date [ ] Bot.# [ ] Kind of Soln. [ ]
Drop/ Drip Factor [ ]Time Started [ ]
Volume [ ] Nurse Sig. [ ]
Medication Sheet [ ]
Date [ ] NHD [ ] Medications : Generic
Name [ ]
Brand Name [ ] Frequency [ ] Dose
[ ]
Time Element [ ] NOD sign [ ]
Nurses Notes [ ]
Date [ ] Shift [ ] Time [ ] Diet [ ]
NOD sign [ ]
M.R. Checklist Date Accomplished:
______________
Signature of Personnel In-charge:
_______________

Note: Each page of the Medical Record must

have complete patients name, date admitted,
sex, and age. All spaces must be filled up
correctly. No erasures please. But if you made a
wrong entry do not use correction fluid to erase
it rather make a single line over the wrong entry,
write the correct entry above it and sign.
Thank you. The MR Management.