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
Aetna, a CVS Health Company, and the PA Clinical Network Announce Value-Based Contract
Working with Aetna in a Value-Based ContractThe PA Clinical Network is uniquely positioned to work with independent practices and health insurers in PA to improve quality and outcomes within our members’ patient populations. As such, the PA Clinical Network (PACN) has...
This content is restricted to site members. If you are an existing user, please log in. New users may register below.