History

What Works: Effective Practices for Office-based CareDocumentation of Patient Assessment
History

Recommendation: A complete history is updated at the time of the annual exam and includes past medical history and family history.

Source: CRICO/RMF Office Practice Handbook



 Effective Practice
Standard physical exam form with prompts for family history and past medical history.
Benefits:
  • Facilitates documentation.
  • Includes all components related to personal and family medical history.
  • Can be paper or electonic.
In practice at: CHA (all sites), MGH (Pediatric Practices), NWH (Pediatric Practices), Granite Medical (HVMA)


 Effective Practice
Use of an interval history form ensures all patient information, history, and lifestyle indicators are updated at each office visit.
Benefits:
  • Facilitates documentation.
  • Incomplete information can be completed during the patient encounter.
  • Can be paper or electonic.
In practice at: Levinson Harris Medical Group (MGH)


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