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.

Chief Complaint: 
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