Page 19 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

☐ Allergies or a notation of “No Known Allergies” which are
clearly flagged in a conspicuous manner and consistent

throughout the record

☐ Current, dated medication flow sheet listing past and
present medication regimens (including over-the-counter
and “PRN” medications)

☐ Current, dated problem list

☐ Tracking mechanism for preventive health screenings

☐ Chief complaint or purpose for the visit, as expressed by
the patient

☐ Objective finding

☐ Diagnosis or medical impression, clearly outlining the
differential diagnosis and decision-making process for

a treatment plan that is clearly and completely defined,
including diagnostic and radiological test results and

treatment administered

☐ Treatment results, including complications and sequelae

☐ All instances of non-compliance or contributory action
(including missed and canceled appointments)

☐ Referral information and consultant reports

☐ All pertinent discussions with the patient and family
members

» Notification of test and results

» Informed consent and informed refusal discussions
(including any educational material given and

reviewed)

Page 19