Recommendation: End of life decisions for elderly/terminally ill patients are addressed in the medical record.

What should be documented

Current, complete records which assist diagnosis and treatment, and which communicate pertinent information to other caregivers also provide excellent records for risk management purposes.

Missed MI Despite Family History

In this case a 45-year-old woman was seen for atypical chest pain, and questions would emerge later about the adequacy of her diagnostic work-up and communication with her and her family.

Do I need to document all normal and abnormal findings from an examination?

No. However, you should always document "pertinent negatives." Because memory does not serve as well as the printed word, you should list all negative findings that are associated with any of the processes in your working differential diagnosis.