Surgical Chart Data Retrieval Worksheet: Case 1 Analysis Report

This assignment focuses on the analysis of surgical chart data for Case 1. It involves a detailed review of various sections of the medical record, including the face sheet, consent forms, anesthesia records, operative reports, and recovery room records. The student, Aisha, provides answers to specific data elements, such as patient and physician names, admission and discharge dates, diagnoses, and details related to the surgical procedure performed (dilation, curettage, and conization). The assignment follows a grading rubric that assesses the student's ability to identify areas of compliance and non-compliance with chart analysis guidelines, evaluate consent forms, examine pre- and post-anesthesia documentation, and assess the operative report and recovery room record. The analysis also covers aspects like the discussion of risks and benefits with the patient, the type of anesthetic technique used, and the personnel present in the recovery room. The student's responses demonstrate an understanding of medical record documentation and the ability to extract relevant information for chart analysis.

SURGICAL CHART
DATA RETRIEVAL WORKSHEET CASE 01
DATA ELEMENT ANSWER
Student’s Name AISHA
Patient Name Paula P. Paulson
Case Name/Number Case 1
Face Sheet /Admitting Information
Medical Record Number Case 1
Admission Date/ Discharge Date/LOS Admit 04-27-yyyy, discharge 04-29-yyyy, LOS- 2 days
Attending Physician Donald Thompson, MD
Admission Service and Type Surgical, Type 3
Principal Diagnosis Acute and chronic cervicitis with squamous metaplasia
All Consents and Advance Directives completed
and signed
Consent to Admission, consent to Release Information, and advanced
directives signed by patient
Consent for Operation and Anesthesia -
Completed within 24 hours of admission or within
30 days prior to admission?
Dictated by physician on day of admission 04-27, typed on 04-29
1. Did the surgeon discuss the risks
and the benefits of having the risks
and benefits of having the
procedure with the patient?
Yes
2. The action the patient can take to remove
information on the consent form that does not
pertain to them
The patient is incapacitated or he is in a life threatening emergencies
where there is inadequate amount of time present to obtain consent.

Pre- and Post Anesthesia Documentation
Summary of the condition of the patient as recorded
on the post anesthesia evaluation.
The patient’s medical history, family history of diseases, allergies. Checking
of the body systems with respect to cardiovascular, respiratory and
gastrointestinal were checked. Post performing anaesthesia the condition of
the patient was registered and followed.
What type of information is included in the non-
physician notes?
No verbal orders- all the orders are written and signed by the physician.
Anesthesia Record :
The date of postoperative anesthesia evaluation? 04/27/yyyy
Type of anesthetic technique used? General
Operative Report/Pathology
Preoperative diagnosis: Abnormal Papanicolaou smear
Compare the preoperative, microscopic pathologic
diagnosis and the post operative diagnosis. Dilation, cutterage and coniztion was performed. Before operating the intial
diagnosis mentioned abnormal papanicolaou smear and post performing
operation squamous dysplasia. The final diagnosis mentioned that the
condition was acute and squamous metaplasia in nature along with chronic
cervicitis.
Recover Room Record
The name of the personnel present (recovery nurse,
anesthesiologist)
Philip Rodgers, Mary Crawford.