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 September 2024
This practice is a member of the PA Clinical Network (PACN), the only Clinically Integrated Network (CIN) in the country affiliated with a State Medical Society. The PACN enhances collaboration among healthcare providers, leading to improved patient outcomes and satisfaction, as practices can share best practices and resources.
Notes from the Network-August 2023
Notes from the NetworkAugust 2023Here is what your PACN Team and Member colleagues have been up to:Your PA Clinical Network is approaching $4 million in distribution to its members. Geisinger PQS payouts went out recently with UPMC, Highmark, Humana and Aetna coming...
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