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Chief Complaint a description of the symptoms that led the patient to seek the physician’s care.
Present Illness A more specific account of the chief complaint, including time frames and characteristics.
Family or Patient History a review of any major illnesses of family members, including grandparents, parents, siblings, aunts and uncles. Any previous major illnesses or surgeries.
Review of Systems Any systematic review of the body’s ten systems to detect problems not yet identified.
Progress Notes Documentation of each patient encounter, including information obtained in phone calls & refills of rx.
Radiological Reports Reports of any x-ray studies performed in the office.
Lab Reports A copy of the results of any lab work done in the office or a report from an outside facility.
Consultation Reports Any reports from other physicians regarding consultations with the patient.
Medication Administration Some facilities use a separate sheet to log medications given in the office.
Diagnosis or Medical Impression The most recent entry on the progress note will contain the provider’s opinion of the patient’s problem.
Physician’s and/or medical assistant’s identification & signature Experts have suggested that you sign your entire name instead of initials, with your credentials.
Documented Advance Directives A copy of any instructions from the patient regarding end-of-life decisions or the appointment of another person who can give consent for treatment for the patient.
Correspondence pertaining to the patient Any letters or memos generated in the facility and sent out are copied and placed in the chart.
Paper-based Medical Record Usually organized in a standard chart order & placed in a specially designed folder.
Reverse Chronological Order When the most recent documents are placed on top of previous sheets.
Narrative This oldest documentation form and the least structured.
Subjective Statement of what the patient says.
Objective What is observed about the patient when he/she is examined
Assessment Phrase stating what is wrong or the diagnosis
Plan List of interventions to be carried out.
POMR It list each problem of the patient, usually at the beginning of the folder and references each problem with a number throughout the folder.
Created by: Mackey1