Required Documentation
From Guide to YKHC Medical Practices
It is very important that you have good documentation so that the providers coming after you can see what the plan is for your patient. The SRC Unit Director who will be your clinical supervisor will review your records quarterly. Each SRCs coder will also be reviewing your charts and asking for more documentation if necessary.
- HPI - Should ALWAYS be free text!
- Problem List - i.e., PMHx, chronic problems. Should be updated at each visit and reviewed.
- Medications - Medication reconciliation at EVERY visit.
- Allergies - Review with EVERY visit and update as necessary.
- Procedure Hx - Review and update as necessary.
- Social Hx - Review and update as necessary. Tobacco, ETOH, and drugs should be updated by screener at intake.
- Family Hx - Review and update as necessary.
- ROS - At least three systems, at least two pertinent negatives each.
- Vital Signs - Address any abnormally.
- PE - General or problem focused.
- Labs, diagnostics, EKG - Order and review.
- Impression/Plan - Should ALWAYS be free text!
- Visit Diagnoses - Any diagnosis addressed at visit along with a plan for each.
- Follow-up plans - RTC, phone call, transfer, etc.
- Patient Education - Pertinent to visit diagnoses.
- Patient Summary - Print and provide before patient leaves clinic.
- Patient signature - Required if patient gets medication, copy and upload to Multimedia.
