How to Create a Medical Encounter Form

A medical encounter form is a form patients fill out when they are seen by a physician, hospital or medical facility. Encounter forms are documentation of patient demographics and medical history. Physicians need to know who they are treating and how to contact them. They also need to know the history of the present illness and factor in any allergies or special needs a patient has into the treatment plan. Examples of encounter forms can be downloaded from the American Association of Family Practice (AAFP) website or can be created to suit your practice.

Instructions

• 1

  Create a new word processing document. Encounter forms can be formatted using Microsoft Word or Pages on an Apple computer.

• 2

  Format the encounter form with patient demographics first. Include enough line space for the patient to write his name, address, contact information and personal health information.

• 3

  Include a section for medical insurance information and duplicate it---many patients have dual coverage under separate health insurance plans. You will need the name of the insurance company, name and date of birth of the card holder, policy number and group number.

• 4

  Document the next section with medical history on the patient. Gather as much information as possible. Ask if the patient has a family history of medical problems such as high blood pressure, cancer or diabetes. Ask if the patient has any allergies or recent surgeries.

• 5

  Tailor your questions based on your medical specialty. For example, a pediatric clinic will want to know different information than will an obstetrics and gynecology practice.

• 6

  Type your next section based on the doctor's point of view. Include information he will need to accurately chart this visit. For example, patient height, weight, vital signs, lab tests.

• 7

  Format a checklist or chart for the physician to complete a multi-system evaluation. This may include an examination of the patient's cardiovascular, respiratory and neurological systems.

• 8

  Include an assessment area for the physician to diagnose the patient and plan the course of treatment. Make a headline for medications prescribed.