-
Legibility & Organization
-
Write EVERYTHING down
- if you didn't chart it, you didn't do it
-
Name, DOB, Age, Gender, Date, Page #, & CC
- ON EVERY PAGE!!!
-
Subjective
-
How pt is doing
-
in their own words
- what is going on w pt?
-
HPI
-
History of presenting illness
-
PQRST
- LMNO
-
FH/SH
- Family and social history
- Diet/OH/drugs/nicotine/caffeine/water
-
ROS
- Review of Systems
-
Objective
- What doctor observes about pt
-
Vitals
- BP, RAS/LAS, pulse, bpm, rrr, temp, resp rpm
-
PE
- Physical Exam
-
M/E
- mental/emotional
- Lab results
-
Assessment
-
Dx
- ICD-9 code
- What you assess about the pt's condition and response to trt
- most likely cause of condition
- if labs are ready, chart how the results lead you to your dx
- S + O = A
-
Plan
-
Trt protocol
-
everything you did today
- massage
-
prescriptions
- Rx, supplements, herbs, homeop
-
recommendations
- diet, hydro, exercise, mental health
- Labs ordered/done
- What to do next visit
- return to clinic as needed (RTC PRN)
-
PARQ conference completed
- Plan Alternative Risk Questions