Skip to Content
Advertisement
Search Icon
Search...
Search Hint
User Tools Link
Login
Search Icon
Menu Icon
Guidelines
At A Glance
Anesthesia
Aseptic Technique
Emergencies
Hand-Over Tools
Instruments
Medication
OR for Infection Preventionists
Pediatrics
Positioning
Procedures
Room Setup
Scrub Role
Skin Prep
Sterile Processing Basics
Vetted Links
Procedures in Action
A Glimpse into Infection Prevention
An Inside Look at OR Efficiencies
Tools
FAQs
Specialties
ASC Infection Prevention Policies and Procedures
Resources for Cardiac Catheterization
Resources for Endoscopy
Guidelines and Tools for the Sterile Processing Team
NAON Books
ARIN Books
Core Curriculum for the RNFA
Perioperative Care of the COVID-19 Patient
Accreditation
AORN ACCREDITATION ASSISTANT
Joint Commission Standards
Ambulatory
Critical Access Hospital
Hospital
Office Based Surgery
Sterile Processing
AAAHC Standards
Accreditation for Ambulatory Health Care
Accreditation for Medicare Deemed Status
Devices
Equipment and Supplies Finder
Device Video Instructions
CineMed
Home
Joint Commission Accreditation
Office Based Surgery
Record of Care, Treatment, and Services (RC) Standards
RC.01.01.01 The practice maintains complete and accurate clinical records.
EP7 Dated entries
Navigation
X
Record of Care, Treatment, and Services (RC) Standards
RC.01.01.01 The practice maintains complete and accurate clinical records.
EP1 Components of the medical record
EP5 Information on the medical record
EP7 Dated entries
RC.02.01.01 The clinical record contains information that reflects the patient's care, treatment, and services.
EP2 Clinical information
RC.02.01.03 The patient's clinical record contains documentation on any operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
EP1 Operative or other high-risk procedures
EP2 Provisional diagnosis
EP5 Operative report
EP6 Operative report information
EP7 Operative progress note
EP8 Postoperative information
EP9 Post-sedation or postanesthesia care
EP10 Discharge criteria
EP11 Practitioner responsible for discharge
Search Icon
Search...
Print
Element of Performance
Date all entries in the medical record.
Resources
Access to this content requires a facility subscription to both eGuidelines+ and the AORN Accreditation Assistant for The Joint Commission.
If your facility has a subscription, please check with them about accessing this resource.
Access Options
If you would like to learn more about purchasing a facility subscription to this content, please click the button below.
Learn More