How to Write a Patient Information Sheet

If you're a nurse or physician's assistant in a doctor's office, one of the first procedures you must learn is how to write a patient information sheet. While there are different types of patient information sheets, the most common is the patient intake form, used to record information on new patients. According to Chiro Touch, a maker of software for use in chiropractic offices, patient information sheets are essential to patient management because they make it easy to record details about a patient's medical history and also to retrieve personal information.

Instructions

• 1

  Enter the patient's contact information. A standard patient intake sheet used by Retina Consultants of Seattle includes the patient's full last and first name, home and mailing addresses, home and cell phone numbers, date of birth, social security number and employer.

• 2

  Enter insurance information, which identifies who is primarily responsible for paying the fees for treatment.

• 3

  Include the treatment authorization language that is standard on most patient information sheets. Retina Consultants of Seattle has patients sign a statement attesting that the patient authorizes the doctor to treat her and will pay for any fees connected with the doctor's services. The statement also authorizes the doctor's office to release patient information to third parties covering costs, usually an insurance company.

• 4

  Note specific information about the chief complaint, the reason the patient came to the doctor. Specialists commonly ask for this information. For example, Beckley Family Chiropractic asks patients to rate their pain on a scale, describe the location of the pain and specify when and how the pain started.

• 5

  Record the patient's medical history. Beckley Family Chiropractic, for example, wants to know whether the patient has previously sought treatment for the chief complaint and if so, who the primary physicians were and whether X-rays, blood tests or bone scans were done for diagnostic purposes.

• 6

  Record the patient's personal preferences regarding disclosure of medical information. For example, the Center for Dermatology Care asks how the patient prefers to receive medical information (e-mail or phone) and whether the patient authorizes the office to discuss her condition with family members.