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Patient Chart and Victim Registration

POLICY:
The Medical Records Director, or designee, shall be responsible for initiation and maintenance of medical records for incoming casualties and patients who were in the hospital prior to the emergency situation.

MULTI-CASUALTY INCIDENT PATIENT CHART:
This is the patient record which is started upon arrival in the triage area during an emergency.

The top portion consists of the basic patient information. Be sure to list the field tag number if one is present on the victim.

One copy goes to Emergency Operations Center.

One copy goes to Radiology/Lab if services are ordered by physician.

The chart remains with the patient until admitted or discharged and is used to document patient care.

The charts are to be completed upon arrival of the victim to a department and sent via a runner to Emergency Operations Center. This guarantees tracking of the patient and his/her ultimate destination. (Discharged/Admitted/Expired)

VICTIM REGISTRATION LOG:
This is used to register all victims brought to the hospital. It serves a dual purpose of patient registration and as the source of information for Red Cross Disaster Welfare Inquiry. A copy of the log is given to the Hospital Red Cross Disaster/Liaison Nurse to be phoned in or sent into the Red Cross Office, Disaster Welfare Inquiry Service, and copy to EOC.

Note: Victim registration log available from Red Cross.

TRANSFER PROCEDURE:
These guidelines shall be followed to ensure that the proper records of patient transfers are kept:

Sufficient clerical personnel, equipment and supplies must be provided to be able to locate patients moved in case of emergencies.

A record will be maintained on all patients transferred to other facilities for any reason.

A Transfer Form will be placed in the medical record of any transferred patient.

The Transfer Form and copies shall be distributed as follows:

A copy is sent to the receiving facility to which the patient is transferred.

One copy of the completed Transfer Form must be placed in the patient's medical record.

US Patent Numbers 7,720,998 B2, 7,836,207