Examples Of Documentation Worksheet
University of Phoenix Material
Documentation Worksheet
Using the following table, identify and list at least three documentation requirements for a history and physical. Describe each documentation requirement in 50 to 150 words.
Documentation requirement
Description
Chief Complaint
The chief complaint is a short record explaining the indications for the reason for the visit. The patient’s explanation of the what is going on is the chief. The visit is considered not needed if the chief complaint is not written in the record. A chief complaint can be placed in the patient’s file when the patient calls in to be seen by the doctor.
History of Present Illness
The history of the present illness is a timeline for when the illness began to how
Documentation Worksheet
Using the following table, identify and list at least three documentation requirements for a history and physical. Describe each documentation requirement in 50 to 150 words.
Documentation requirement
Description
Chief Complaint
The chief complaint is a short record explaining the indications for the reason for the visit. The patient’s explanation of the what is going on is the chief. The visit is considered not needed if the chief complaint is not written in the record. A chief complaint can be placed in the patient’s file when the patient calls in to be seen by the doctor.
History of Present Illness
The history of the present illness is a timeline for when the illness began to how