Friday, September 7, 2007

Ingredients For Standard Reports

Before you lift the phone to start dictating, glance through the chart in front of you to get some ideas about how you want to organize your thoughts about the patient's past, current, and future care. For example:

A history & physical, consultation, transfer summary, discharge summary, or Emergency Room report may include the following intelligent building blocks:

  • Patient Demographics

  • Patient Care Team

  • Copies

  • Chief Complaint

  • History of Present Illness

  • Past Medical History

  • Past Surgical History

  • Family History

  • Social History

  • Occupational History

  • Current Medications

  • Allergies

  • Review of Systems

  • Physical Examination

  • Hospital Course

  • Laboratory Studies

  • Discharge Medications

  • Discharge Activities

  • Discharge Diet

  • Discharge Plan

  • Prognosis

  • Discharge Diagnoses

  • Condition of Patient

Next: Ingredients For Surgical Reports

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