Posted by: Edelberg & Associates
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- List your impressions and differential diagnoses
- Document review of current meds and medication reconciliation
- Document medical care provided prior to patient’s arrival (e.g. EMS)
- Note information obtained from sources other than the patient (parent, guardian, relative, caregiver, nursing home)
- List all interventions and procedures, medications including route of administration, re-assessments, response to treatment, changes in status that may outweigh the presenting problem
- Document pertinent details of discussions with PCP and/or consultants
- Note pertinent contents of any old records reviewed
- Document impression of ancillary test results
- Record “per my review for EKG or imaging studies not formally interpreted
- Record discharge instructions including medications, and follow-up
- Give a definitive time frame for a phone or office follow-up
- Document the diagnosis(es) and list all that are pertinent
- Remember to note acute or emergent when applicable
- Review Nurses Notes for accuracy in supporting orders, interventions, disposition