Page 27 - Part Two Risk Reduction Series - Documentation
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SVMIC Risk Reduction Series: Documentation
a comprehensive medical and family history; medication and
allergy history; the chief complaint or purpose for the visit; all
relevant positive and negative clinical findings; your diagnosis or
medical impression; the decision-making process for the clearly
defined treatment plan; and all relevant instructions and
information given to the patient regarding such treatment plan.
Ensure anyone with access to the medical record is familiar with
the location of documenting critical information. For instance,
allergy information and immunizations should always be recorded
in a designated location of the medical record for at-a-glance
review.
A thorough note does not equate to volume. In fact, precise but
accurate, objective and descriptive documentation can convey
more medically relevant facts than a note full of repeated and often
irrelevant information. In most cases, documenting enough to
evidence individualized care including the objective assessment,
along with your impressions, differential diagnoses and plan will
adequately tell the story of the care provided and follow-up plan.
Don’t assume that the patient will tell you everything that’s
important. Your duty is to elicit all relevant details of the medical
history. Failure to take and record an adequate medical history and
physical examination is a primary factor in claims alleging missed
or delayed diagnosis.
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