Documentation

Documentation is the process by which we record health observations, assessments or plans so that they can be shared with other members of the healthcare team. Documentation Norms are covered elsewhere, including expectations for meaningful problem, diagnosis, medication, adverse reaction, clinical and encounter documentation.

Special Documentation Workflows

• • FAQ: Adding information to the chart of a deceased patient

More Information

Subsections address important documentation workflows, tasks or processes.

• Problem List Management

• History Management

• Problem Oriented Charting

  • History & Physical Note

  • Consult Note

  • Operative Note

  • Discharge Summary

  • Subjective-Objective Note

  • Progress Note

  • Clinical Summary Note

• Immunization Documentation

• Exceptional Care Plans

• Forms

  • Letter Forms

• Norms

• Sidebar Activities

• Shared Documents

Resources

• • Norms: Documentation (Prescribers)