Admission History and Physical - Provincially Standardized Templates

Standardized charting, including Problem Oriented Charting (POC), is most efficient when started at the beginning of an inpatient encounter, using structured documentation (e.g., problems, medical history, medications) before composing any histories, consults, notes or summaries. This section explains how to find and use standardized History and Physical documentation templates in  Connect Care.

Resources

• • Tip: Finding Standardized Documentation Templates

  • Norms: Documentation (Prescribers)

  • Manual: Problem Oriented Charting