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Patient Safety Strategies
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Office Practice: What Works
> Medical Record & Documentation
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The Medical Record and Documentation
Components of the Medical Record
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Legibility
Master Problem List
Medical Record Organization
Medication List
Patient Demographics
(Recommendation 1)
Patient Demographics
(Recommendation 2)
Signatures and Dates
Documentation of Patient Assessment
view all
Advance Directives
Allergy Status
Functional Assessment
Health Care Proxy
History
Lifestyle Indicators
Physical Examination
Review of Systems
Unresolved Problems
Documentation of Patient Outcomes
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Health Counseling
Health Education
Time of Return
Treatment Plan
Working Diagnosis
