Medical Documentation Checklist Form
Use this Medical Documentation Checklist Form to coordinate and track medical documentation intake efficiently.
Patient or Documentation Reference
*
Submitting Department or Clinic
*
Please Select
Outpatient Clinic
Inpatient Ward
Radiology
Laboratory
Emergency Department
Surgery
Other
Document Type or Category
*
Please Select
Admission Note
Discharge Summary
Progress Note
Consultation Report
Lab Report
Imaging Report
Referral Letter
Other
Date of Service or Document Request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Required Documentation Checklist
*
Patient Demographics Sheet
Physician Signature
Diagnosis Documentation
Treatment Plan
Consent Forms (if applicable)
Optional/Extra Documentation Checklist
Insurance Information
Medication List
Social Work Notes
Patient Education Materials
Other
Notes or Missing Items
Priority/Urgency
*
Routine
Urgent
Stat
Responsible Staff Member
*
Submission Status / Completion Confirmation
*
Complete
Incomplete
Pending Review
Submit Checklist
Should be Empty: