Documentation/Charting

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