In order to obtain the necessary medical records from the records department of the hospital for the recent surgery a patient of your gynecologist office had to address the abnormal bleeding will require a release of information form to be completed. This written consent form allows hospital staff to provide your office with the records of services performed. The hospital may have additional guidelines for the release of the records they will provide you with upon contact with them.
Information generally needed for the consent form will be the patient name and identification number, age, weight, date of birth to be sure. A specific request for the lab reports should also be included due to the initial complaint.
Once obtained, this record will include any SOAP notes from all members of the medical team handling the patient. Other than the doctors’ notes, there may be notes from therapists, nurses, and dietary staff, to name a few. Also included in this report will be a detailed description of what was done, by whom and when. Results of testing that was done, medication prescribed, therapy recommended, recheck dates, will also be in the record in the order of occurrence.
Additionally, the vital signs such as blood pressure, heart rate, temperature, and rate of respiration before and after the procedure will also be noted in the records.
Upon review of the file, the file should start with the proper name of the patient, the current date, the dates of the time in the hospital, the surgeons’ name, history of past medical conditions, and the new condition and complaint as well. This is followed by the family history, pre operation and post operation testing done and the results, the results of the surgery, what was found, and any complications that occurred or to watch for following the surgery.
The focus of the records for the purpose of this office will be the