Are They a New or Established Patient?
It is important to determine this at the beginning since it will help you determine requirements in your documentation.
They are a new patient if they have not seen a medical provider at Family Health Center in the last 3 years. This could be in Urgent Care, School-Based Health Centers, Elm Park, Webster Square or on a Team. This does not include Dental or Mental Health. If you have a chart with no notation, it is wise to ask the patient, since documentation may not have made it into the chart before you saw the patient.
This is the reason the patient is there to see the provider. There may be more than one reason. If it is for a follow-up visit, it must state the condition that is being followed: i.e., follow-up on asthma, diabetes, rash, etc. “Routine” is not an appropriate statement.
Parts of Documentation:
1. History of Present Illness Review of Systems Past, Family and Social History
2. Physical Exam
3. Presenting Problem to Treating Provider Amount and/or Complexity of Data to be Reviewed Risk of Complications/Morbidity/Mortality