Post-Encounter (Ongoing):
Posted: Tue May 20, 2025 9:47 am
Immunization history
Review of Systems (ROS) - checkboxes or questions about symptoms across different body systems.
Consent Forms: HIPAA privacy notices, consent for treatment, financial responsibility forms.
During the Clinical Encounter (with the physician/medical assistant):
This is where the direct clinical data collection happens, building upon the initial information.
Data Collected:
Chief Complaint: The patient's primary forex database reason for the visit, in their own words.
History of Present Illness (HPI): Detailed information about the chief complaint (onset, duration, severity, modifying factors, associated symptoms).
Physical Examination Findings: Objective observations made by the physician during the exam.
Assessment/Diagnosis: The physician's professional evaluation and diagnosis(es).
Plan of Care: Treatments, prescriptions, referrals, follow-up instructions, ordered tests (labs, imaging).
Procedures Performed: Documentation of any in-office procedures.
Patient Education: Information provided to the patient.
Test Results: Lab results, imaging reports, pathology reports are integrated into the patient's record.
Referral Updates: Information from specialists the patient was referred to.
Review of Systems (ROS) - checkboxes or questions about symptoms across different body systems.
Consent Forms: HIPAA privacy notices, consent for treatment, financial responsibility forms.
During the Clinical Encounter (with the physician/medical assistant):
This is where the direct clinical data collection happens, building upon the initial information.
Data Collected:
Chief Complaint: The patient's primary forex database reason for the visit, in their own words.
History of Present Illness (HPI): Detailed information about the chief complaint (onset, duration, severity, modifying factors, associated symptoms).
Physical Examination Findings: Objective observations made by the physician during the exam.
Assessment/Diagnosis: The physician's professional evaluation and diagnosis(es).
Plan of Care: Treatments, prescriptions, referrals, follow-up instructions, ordered tests (labs, imaging).
Procedures Performed: Documentation of any in-office procedures.
Patient Education: Information provided to the patient.
Test Results: Lab results, imaging reports, pathology reports are integrated into the patient's record.
Referral Updates: Information from specialists the patient was referred to.