• Admission face sheet
• Consents, except operative consents
• Inventory sheet
• Living Will. Although this form may have been signed prior to admission, it can be placed behind documents from the admission date.
• Durable Power of Attorney. This form may also have been signed prior to admission.
• Leave of absence forms.
• Transfer forms generated by the hospital when it is sending a patient to a nursing home or another hospital. The transfer form can be the last form in this section.

Emergency Room Records

History and Physical

Discharge Summary. You can include both the physician and nursing discharge summaries or the nursing discharge summary can be placed at the end of the nursing notes.

Consultations (unless the consult notes are integrated within the Progress Notes)

Orders

Progress Notes

X-Rays/EKGs

Surgeries and Procedures. If more than one procedure or surgery occurred, group them chronologically by each procedure or surgery, separated by a tab or piece of colored paper.

• Typewritten operative reports
• Pathology report (if there is one)
• Anesthesia reports
• Intraoperative reports
• Recovery room
• Operative consents

Nursing Assessment / Care Plans. Place the nursing assessment form first, followed by any other random assessments from the day of admission, followed by care plans.

Nursing Notes

• If there are flow sheets that are separate from the nursing notes, the flow sheets can be grouped to precede or follow the nursing notes.
• For multiple-paged flow sheets, ensure that each date has all forms in the same order.

Medication Administration Records (MARs)

Decubitus/Skin Reports

Graphic Sheets

Intake and Output Sheets

Therapies. These include Physical Therapy, Occupational Therapy, Speech Therapy, and Respiratory Therapy. Group chronologically by each therapy separated by a tab or piece of colored paper.

Social Services / Case Management / Discharge Planning.