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

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• 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