Final answer:
The physician's requisition form for an inpatient must include the patient's complete name, DOB, medical record number, name of the procedure, confirmation of needle, sponge, and instrument counts, correct specimen labeling, and any equipment issues.
Step-by-step explanation:
When preparing the physician's requisition form for an inpatient, several pieces of information must be accurately and completely recorded to ensure the safe and effective delivery of healthcare services. The requisition form serves as a critical communication tool between the physician and various departments within the healthcare setting, such as the laboratory, radiology, or surgical services.
First and foremost, the complete name and date of birth (DOB) of the patient must be included to accurately identify the individual receiving care. This is standard practice for verifying the identity of the patient and preventing any potential errors. In addition to this, the patient's medical record number is essential, as it serves as a unique identifier for the patient's health record within the hospital or healthcare system.
Beyond the basic identification information, the requisition form should clearly state the name of the procedure that is to be performed. This specification assists healthcare professionals in preparing for the appropriate intervention or diagnostic test. Following a surgical or invasive procedure, the team must conduct a count of all needles, sponges, and instruments used to ensure that nothing is left inside the patient accidentally. The count should be noted as either complete or not applicable, depending on the situation at hand.
If a specimen is taken during the procedure, the form must include information about the correct labeling of the specimen, which includes the patient's name, to ensure it is not mixed up with other patient samples. This is a vital step in the chain of custody for the specimen and for accurate diagnostic reporting.
Furthermore, any issues with the equipment that are known before or arise during the procedure should be highlighted on the form, allowing for proactive management and avoiding delays or complications during the procedure.
To summarize, in addition to the basics of patient identification, the physician's requisition form should encompass procedure details, counts related to surgical items, specimen labeling, and notation of equipment issues. These components work together to maintain patient safety and facilitate high standards of care.