Physician Documentation Requirements

When it comes to patient care, one of the most vital tools a doctor has is good documentation. It may not sound terribly important, but a thorough file on a patient can contain vital information relevant to treatment. It also allows doctors to follow a patient's progress and alter treatment as necessary. When writing up patient documentation, there is little room for sloppiness if an accurate and useful record is to be kept. To that end, patient documentation follows a set of guidelines to ensure high quality.

Chief Complaint

• One of the first things that goes into a patient record is the Chief Complaint (CC), or reason the patient has come to the doctor. The CC is described briefly, be it a list of symptoms, a preliminary diagnosis or a visit on the recommendation of another physician. This description is usually stated in the patient's words.

History

• Next, a history is taken. This history includes the history of the CC, including factors like location, severity and modifying factors. It also includes a review of body systems that may be affected by the CC. The doctor asks about the patient's constitution (fever, weight loss, etc.), her eyes, ears, nose, mouth and throat and other systems. These questions help identify potential signs or symptoms the patient is experiencing or may have experienced. The history also includes the patient's prior medical history, relevant family history and social activities.

Physical Examination

• The doctor then performs a physical examination. This exam may be limited to relevant regions of the body or may encompass a broader examination. The findings of the examination are noted in the patient record.

Diagnosis, Treatment and Risks

• The doctor must note the diagnosis or diagnoses, if necessary. He must also record possible treatment and management options, the amount and complexity of the data to be reviewed, and the risks of complication or mortality associated with the diagnosis and treatment.

Referrals and Consultations

• If a referral is required, the doctor must document it, noting which doctor she is referring the patient to.

Patient Education and Follow-Up Care

• The doctor must also make a note of any information given to the patient regarding his diagnosis and/or treatment. Any recommendations for follow-up care, including further visits, should also be noted.

Test Results

• The record should include a copy of any tests performed.

Prescriptions and OTC Drugs

• Any prescription or over-the-counter drugs should be listed, with dosage, in the record.