Documentation is based on predetermined standards of practice.
It is imperative that the standards be used as a daily reference for the plan of care for the patient and that any deviation from the standard be documented. These standards are meant to provide a minimum standard of practice for each patient. Outpatient Documentation of care is based on a problem-oriented approach. The problem list provides an ongoing summary of diagnosis and conditions, procedures, drug allergies and medications. The list will be reviewed and updated as appropriate.