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 Year-end: Reflections on 2024
Notes from the NetworkDecember (Year-end) 2024[lwp_divi_breadcrumbs home_text="Notes from the Network" use_custom_home_link="on" home_link="/notes-from-the-network" _builder_version="4.27.4" _module_preset="default"...
2023 Annual Meeting
Annual MeetingThe PA Clinical Network Annual Meeting was held on September 27th. The hybrid event featured speakers from our board, as well as guests like Dr. Wilson Jackson, President of the PA Medical Society, Dr. Damian McHugh, Senior VP & Physician Liaison at...
This content is restricted to site members. If you are an existing user, please log in. New users may register below.
