Question | Answer |
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. |