As health care providers function under increasing time constraints, well-designed forms can help simplify and improve the documentation process. Patient record forms can help clinicians identify essential points of the history and physical examination and can provide anticipatory guidance. This article presents one documentation system that primary care providers may find effective in their documentation efforts. Although documentation is time consuming, it is a vital and mandatory component of patient care. Several clinical and regulatory issues must be considered when documenting care.
Clinicians can document patient visits using forms that greatly simplify and improve the process.
Forms should clearly display important information, enable communication with other health care providers, and structure information gathering to expedite patient care. Additionally, forms should provide rapid and easy documentation supporting the appropriate codes for reimbursement systems. The initial use of new forms requires clinicians to become familiar with the form, including the rationale for the components. Form Development Well-designed forms facilitate thorough, consistent, and concise performance of a complete history and physical examination. The goal of form development is to facilitate comprehensive, yet concise, patient care performance and documentation.