1.
This method includes database; problem list; educational, diagnostic, and treatment plan; and progress notes.
2.
Words-to record the patient's exact words rather than your interpretation of them.
3.
Includes Chief complaint, history, examination, details of problem and complaint, drug and dosage, assessment, return visit.
4.
Always remember that the information in patient records and forms is confidential and is considered to be PHI.
5.
Patient information is arranged within the medical record according to the provider type supplying the data.
6.
An approach to medical records documentation that documents information in order such as sub-subjective data, objective data, assessment, plan of action.
7.
In short means brief and to the point.
8.
Fill out completely all the forms used in the patient record.
9.
Order-Entries in the patients records must be dated to show the order in which they are made.
10.
Use precise descriptions and accepted medical terminology when describing a patient’s condition.
