YCS MEDICAL RECORDS –TABLE OF CONTENTS- Residential Chart
SEE MEDICAL DEPARTMENT CHART TO REVIEW THESE DOCUMENTS
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Table of Contents
Medical Records Purge Form
Medical Personnel List
Section 1 Admission Records
1.1Comprehensive Intake PC Assessment from Social Service Dept
1.2Copy of Medicaid Card and any secondary Insurance Cards
1.3Admission Checklist
Consents
1.4Emergency & Non-emergency medical and dental release form
1.5Authorization to release medical information
1.6Consent for Dental Treatment
1.7Non-Psychotropic Medication consent
1.8Consent for HIV testing
1.9Substance Abuse screening Consent form (8/10)
1.10Family Life Curriculum
1.11Heat Related Education and signature page (1/04)
1.12Sewing permission and policy (1/09)- as needed
1.13Pre-admission Information: Place copies of all preadmission documents in this sections including:
1.13 a.EKG tracing and report
1.13 b. Physical Control Clearance form- prior to admission
1.13 c. Preadmission TB screening form
1.13d. Pre-Admission History and Physical
Section 2 – Physician/APN Section
Pediatric Section
2.0Chart Tracker
2.1Pediatric Progress Notes
2.2On-call Telephone Note/Record
2.3Annual History and Physical Assessment Form
2.4Admission History and Physical Examination and Assessment Form
2.5Physician/APN Transfer form
2.6Medical Clearance for Physical Control Form
2.7Asthma Action Plan
2.8Anaphylaxis Action Plan
Psychiatric Section
2.9Psychiatric Progress Note
2.10Monthly Psych. Medication Review
2.11Annual Psychiatric Evaluation
2.12Admission Psychiatric Evaluation
2.13Checklist for AIMS Examination Procedure form
2.14Psychotropic Medication Clinical Admission Assessment
2.15Letter to Dr. Beirne for Request for DYFS Physician Sign off Letter (as needed)
Section 3 Medication and Order Sheets
3.1Pharmacy Consultant’s Notes
3.2Comprehensive Medication History
a. Comprehensive Medication History (pre-admission)
b. Comprehensive Medication History
3.3Physician Order Sheets (Newest on top)
3.3aPhysician Order Sheet (lined)
3.3bIPPC Physician Order Sheets
3.3cOTC Admission Orders
3.3dAdmission orders
3.4Physical Control Order Sheet and Post PC Nursing Assessment
3.5Med. Administration Records (MARs)
3.6Controlled Substance Tracking Sheets
3.7Medication Alert Forms
3.8Behavior Side Effect Monitoring Forms (CCW)
3.9School Psychotropic Medication Evaluation Form
3.10Informed Consent for Psychotropic Medications
3.11Consumer Education Form- Age 5-12 or Age 12 and older
3.12Medication Information from Pharmacy for each medication
3.13Pharmacy (IPPC) HIPPA form
3.14Pharmacy (IPPC) Client Information Data form
3.15Pharmacy (IPPC) communication form
3.16Pharmacy (IPPC) permission to deliver to site form
3.17Pharmacy (IPPC) financial responsibility form
Section 4 Nurses Section
4.0Chart Tracker from
4.1Recommended Immunization Schedule- CDC
4.2NJIIS form with Immunizations
4.3Missing Vaccine Records- NJIIS
4.4Consent for Information to be placed into NJIIS
4.5Vaccine Consent Form
4.6VIS (Vaccine Information form)
4.7Nurses Progress Note
4.8Post AWOL Nursing Assessment
4.9Post AWOL Staff form
4.10On-call Nurse Telephone record
4.11Correspondence
4.12Medical Alert Forms
4.13Medical Complaint Form
4.14Annual Nursing Assessment From
4.15Admission Nursing Assessment Form
4.16Transfer Nursing Assessment Form
4.17Nursing Care Plans
4.18Monthly Nursing Summary
Section 5 Labs, X-rays, and Diagnostic Tests
5.1EKG Tracing and Report
Section 6 Nutrition
6.1Nutrition Assessment (1/11)
6.2Dietician Progress Notes
6.3Growth Chart
6.3.1Male Growth Chart 2-21 yrs
6.3.2Female Growth Chart 2-21yrs
6.4Diet Alert Form
6.5Vital Sign/ Height and Weight Tracking
Section 7 Dental
7.1Dental
7.2Orthodontist
Section 8 Medical Consultants and Specialists Reports
8.1Medical Referral Form
8.2Ophthalmology/optometry Form
8.3Consultation Referral Form and letter
Section 9 Discharge Forms and other forms
9.1Residential Alert Form
9.2Enuresis
9.2a.Enuresis Tracking form
9.2b.Enuresis Consent and Policy
9.3Encopresis Tracking Forms
9.4Menstruation Tracking Forms 9.7 Discharge Forms
9.5 AsthmaPeak Flow Forms9.7.a. Physician/APN Discharge Form
9.6 Home Pass Medication Forms9.7b. Discharge Medication Information
Revised 2.7.11