The following must be recorded :
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• Blood pressure , height , weight , and body mass index
• Immunization record
• Tobacco habits , including advice to quit , alcohol use and substance abuse for members age eleven ( 11 ) and older
• Family and social history
• Preventive screenings / services and risk screenings
• Acknowledgement on all critical laboratory values with the providers signature or initials and date
• Screening for depression and evidence of coordination with behavioral health providers
• Advanced directives ( where appropriate ), including documentation of refusal
• HIPAA education and acknowledgement
Demographic information should include :
• Member name and date of birth , or member name and health care ID number , on every page
• Gender
• Age or date of birth
• Address
• Marital status
• Occupational history
• Home and / or work phone numbers
• Name and phone number of emergency contact
• Name of spouse or relative
• Insurance information
For each visit , documentation should include :
• Member ’ s complaint or reason for the visit
• Physical assessment
• Unresolved problems from previous visit ( s )
• Diagnosis and treatment plans consistent with findings
• Growth charts for pediatric members
• Member education , counseling or coordination of care with other providers
• Date of return visit or other follow-up care
• Review by the primary physician ( initialed or signed ) on consultation , lab , imaging , special studies , and ancillary , outpatient and inpatient records
• Consultation and abnormal studies are initiated and include follow-up plans
• Chronic illness and interventions are addressed