Table 1. Medical chart documentation checklist in each component.
Component 1 Informed consent |
Component 2 Resuscitation |
Component 3 Diagnostic imaging |
|
---|---|---|---|
1 | Date, place | Date, place | Date, place |
2 | Patient or family name | Patient name | Patient name |
3 | Explainer, Attender | Present history | Present history |
4 | Patient condition | Electric treatment | Disease name |
5 | Content of medical procedure | Drug treatment | Image findings |
6 | Alternative description | Type of cardiac arrest | Left or Right |
7 | Complications | Differential diagnosis | Initial treatment |
8 | Understanding by patient or family | Communication with medical staff members | Differential diagnosis |
9 | Question and answer | Time course | Time course |
10 | Organized | Organized | Organized |