Page 17 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

The Medical Record in the Office Setting Should

Include

 A demographic page which includes:

 Name of the patient

 Date of birth

 Address

 Phone number

 Next of kin or significant other

 Current insurance information

 A comprehensive health history (updated annually) which

includes:

 A comprehensive medical history - patient’s past

history of illnesses, injuries and treatments, prior
operations and hospitalizations, current medications,

age-appropriate immunization

 A comprehensive family history - health status or cause

of death of the patient’s family members, including

specific and hereditary diseases that may place the

patient at significant risk

 A comprehensive psychosocial history, with significant

information about the patient’s activities and other

relevant social factors such as:

 Marital status, living arrangements, employment,

level of education

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