One way to provide consistently better, more compliant documentation is to create a template or "cheat sheet." Besides documenting the treatment you provide on these visits, create a checklist that prompts you to supply the critical notes for three different types of visits:
Initial Visit or New Episode Be sure your template prompts you to include the patient's history of each complaint, review the systems involved and if applicable, the patient's past, family and social history. Plus...
- Exam findings
Periodic Reevaluation Documenting the patient's progress is not only important, but required. These may follow a similar template as the initial visit, but should prompt you to record details that allow comparison with your original findings so you can demonstrate progress:
- Historical assessment of their progress
- Examination findings that show progress or lack thereof
- Professional assessment
- Diagnosis updates
- Treatment plan changes
Be sure that you include your impression of what indicators point to the effectiveness of your treatment!
Routine Visits Since you're in the midst of executing your treatment plan, certain elements must be included:
- Patient's assessment of their function
- Objective findings
In your daily assessment, include comments about how you can tell the patient is improving and why they need to continue your prescribed plan.
Creating templates to guide your documentation and clinical procedures produce better case management AND better time management.
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