6 History and Physical, SF 511 (T.P.R. Graphic),
SF 510 (Nursing Notes), and Doctor's Orders. Check the patient's health record for
inclusion of these forms and document compliance.
Each form will be checked for date, signature, and
Stamp and insert new forms for use during surgical
experience, if needed,
Acquire required x-ray reports and films as necessary, insert reports
into patient's chart, and document compliance.
Ensure x-rays have been taken.
Check for x-ray results in health records.
(c) If the results are not on the record, call x-ray for results and
write report in comments section. Make an attempt to locate written x-ray report and
(d) Notify the Charge Nurse or physician immediately of previously
Acquire laboratory reports as required, insert reports into the
patient's chart, and document compliance.
Ensure ordered lab work has been done.
Check for laboratory results on health records.
(c) If the laboratory results are not in the record, call the laboratory
for results and write the report in the "comments" block. Make an attempt to locate
written lab reports to place in the patient's chart.
(d) If laboratory reports indicate abnormal values which may not
have been known by the physician and which could influence surgery, notify the Charge
Nurse or physician immediately.
Acquire EKG report as required, insert the report into the patient's
chart, and document compliance.
(a) Ensure EKG was completed for all patients over 40 years of
age and others as ordered.