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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.

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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