Page 26 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

As stated at the beginning of this course, certain elements

comprise the foundation of documentation standards. At a
minimum, document 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.

Consider the following case:

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