Physician Office Record Documentation
Routine healthcare treatment commonly occurs within the physician office setting. Routine services include preventative services such as yearly physicals and blood tests, in addition to diagnosis and treatment of minor illnesses and injuries. In many instances, hospital-based health records can feed into the physician office record if the hospital and physician office records are electronic and information can be exchanged from one health record system to another. Much like a paper-based physician office record, the physician office record that is EHR-based, is often in an integrated health record format.
The physician office record content consists of the following:
- Medical history
- Family history
- Social history
- Vital signs
- Chief complaint
- Progress notes
- Allergies
- Medication list
- History of present illness
- Review of systems
- Assessment and diagnosis
- Plan of treatment
