Page 18 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 Use of street drugs or misuse of prescription

drugs

 Use of alcohol

 Use of tobacco, including smokeless

 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

 Flowsheet or other method to track preventive health

screenings, in primary care setting

 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

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