[SOLVED] Patient Encounter Documentation

Patient Encounter Documentation Grading Rubric {Ten (10) Points}:
Subjective (2 points)
State the patient’s chief complaint, reason for visit and/or the problem for which the patient sought consultation.
All symptoms related to the problem are described using the following cue descriptive categories:
Precipitating/alleviating factors (including prescribed and/or self-remedies and their effect on the problem).
Associated symptoms
Quality of all reported symptoms including the effect on the patient’s lifestyle
Temporal factors (date of onset, frequency, duration, sequence of events)
Location (localized or generalized? does it radiate?)
Sequelae (complications, impact on patient and/or significant others
Severity of the symptoms
Past Medical History including immunizations, allergies, accidents, illnesses, operations, hospitalizations.
Family History includes family members’ health history.
Social history to include habits, residence, financial situation, outside assistance, family inter-relationships.
Review of Systems relevant to the chief complaint/presenting problem is included. Include pertinent positives and negatives.
2. Objective (3points)
Using problem-focused examination re: inspection, palpation, percussion, and auscultation, the examiner evaluates pertinent systems associated with the subjective complaint including applicable systems which may be causing the problem, or which will manifest or may potentially manifest complications and records positive and pertinent negative findings
Performs appropriate diagnostic studies if equipment is available
Records results of pertinent, previously obtained diagnostic studies.
Use Handout Guidelines to Physical Examination.
3. Assessment (3 points)
Diagnosis/es with pathophysiology is (are) derived from the subjective and objective data
Differential diagnoses with pathophysiology are prioritized – (minimum of 3)
Diagnosis/es come(s) from the medical domain
Assessment includes health risks/needs assessment
4. Plan (2 points)
Appropriate diagnostic studies with rationale
Therapeutic treatment plan with rationale
Was this patient appropriate for a nurse practitioner as a provider? Is consultation or collaboration with another health care provider required?
Health promotion/disease prevention carried out or planned: education, discussion, handouts given, evidence of patient’s understanding.
What community resources are available in the provision of care for this client?
Referrals initiated (including to whom the patient is referred to and the purpose)
Target dates for re-evaluating the results of the plan and follow up Patient Encounter Documentation
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