Keeping accurate documentation in the patient’s medical chart is important as it provides information (present and historic) that will help clinicians make sound care decisions. It also could potentially become a legal document, should the need arise.
Documenting the patient’s demographics (name, age, contact information, etc.) as well as the immunization, medication, medical allergies, social history, surgical history, family history, and habits will help to provide the clinician with a ‘picture’ of the patient.
Tips
At every visit, the following information should be part of the patient’s medical chart:
• Patient’s height
• Patient’s weight
• BMI (may need to calculate)
• Chief complaint
• History of present illness
• Medications
• Vital signs (Blood Pressure, Temp, Heart Rate, Respirations)
• Health Risk Assessment
• Depression Screening
• Social determinants of health (concerns for employment, housing, food, transportation, literacy, access
to health care)
Sources:
Social Determinants of Health: www.cdc.gov/social determinants
Charting: www.globalpremeds.com; www.carecloud.com
Approved Quality Committee – 1/8/2020
Notes from the Network-April 2024
Notes from the NetworkApril 2024Performance PaymentsThanks to the great care that our PACN practices provide to their patients, the PACN has distributed more than $4.5 million back to PACN practices for Quality care since inception. Additional payments for 2023...
April 2023 Bulletin
April 2023 BulletinHere is what your PACN Team and Member colleagues have been up to as we begin 2023:PACN-ACO education session was held on February 24th for Quality Reporting (MIPS) submission tips. Thanks to all our PACN-ACO participants for your engagement to...
This content is restricted to site members. If you are an existing user, please log in. New users may register below.
