For clinical documentation tips
- Chief complaint
- History of present illness
- Pain assessment
- Past medical history
- Current medications
- Allergies
- Family history
- Social history
- Primary care physician
- Psychosocial history
- Review of systems
- Physical Examination
- General exam
- Vitals
- System exam
- Pertinent labs and diagnostics
- Admission problems with diagnosis
- Remember to document acuity even when it is obvious include terms like congenital, chronic, acute, acute on chronic, acute exacerbation
- detail process that required the admission or surgery.
- list every disease or condition present at admission that is suspected, tested for, monitored, medicated and link with underlying disease.
- document significance and interdependence of coexisting conditions. Especially think if malnutrition if it is present.
- make sure the following are documented if present
- pressure ulcer, where?
- anemia with cause
- leukocytosis, why?
- pneumonia
- right heart failure
- pulmonary edema, cardio genie or non-cardiogenic
- heart failure?
- acute or chronic osteomyelitis
- Treatment plan