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 the patient is feeling at the time of the visit. When documenting this section there wiil only be four ways to write these notes.The types of writing are problem focused, expanded problem focused, detailed, and comprehensive.
Review of Systems
The review of systems are question to find out any types of symptons and a chance to look for any signs the patient may or may not be aware of at the time of the visit. The nurse, other staff, or the patient can write this statement, but the doctor or the nurse needs talk with the patient about the statement. The statement needs to have a signature and date by the person that reviews the information.
Gartee, R. (2011). Electronic health records: Understanding and using
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Shanholtzer, M. B. (2015). Integrated electronic health records: A worktext for Greenway Medical Technologies’ PrimeSUITE® (2nd ed.). Columbus, OH: McGraw-Hill.