What documentation is recommended for a patient's health, excluding skin assessment?

Comprehensive Documentation Guidelines for Patient Health Assessment

The most comprehensive documentation for patient health assessment should include a detailed medical history, physical examination findings, laboratory tests, and preventive health counseling, all prioritizing morbidity, mortality, and quality of life outcomes.

Medical History Components

• Document previous diagnoses, hospitalizations, treatments, and their severity as part of a comprehensive medical history 1
• Record family history of diabetes, cancer, and other hereditary conditions in first-degree relatives 1
• Document tobacco, alcohol, and substance use history 1
• Assess and record physical activity patterns and sleep behaviors 1
• Document eating patterns and weight history 1
• Record occupational history and environmental exposures 1
• Document history of chronic conditions including:
  • Heart failure 2
  • Renal insufficiency (mild, moderate, severe, or failure) 2
  • Chronic lung disease 2
  • Dementia 2
  • Depression 2
  • Liver disease 2
  • Collagen vascular disease 2
  • Musculoskeletal disease 2
  • Malignancy 2
• Record immunization history, including influenza and pneumococcal vaccines 2
• Document urinary continence status 2

Physical Examination Documentation

• Record vital signs including heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 2, 1
• Document height, weight, and BMI calculations 1
• Record visual acuity assessment findings 1
• Document fundoscopic examination results 1
• Record heart auscultation findings, noting any murmurs, gallops, or rubs 1
• Document lung auscultation findings, noting any abnormal breath sounds 1
• Record abdominal examination findings from inspection, auscultation, and palpation 1
• Document sensory examination and deep tendon reflex findings 1

Current Symptoms Assessment

• For patients with heart failure, document:
  • Presence of dyspnea at rest 2
  • Dyspnea on exertion and the degree of activity required to elicit symptoms 2
  • Orthopnea and positioning requirements for comfortable breathing 2
  • Paroxysmal nocturnal dyspnea episodes 2

Laboratory and Screening Tests

• Document results of core laboratory tests:
  • Complete blood count (CBC) 3, 1
  • Comprehensive metabolic panel (CMP) 3, 1
  • Lipid profile (total, LDL, HDL cholesterol, and triglycerides) 3, 1
  • Hemoglobin A1C 3, 1
  • Urinalysis with albumin-to-creatinine ratio 3, 1
• Record thyroid-stimulating hormone (TSH) results, particularly for women and older adults 3, 1
• Document medication-specific monitoring:
  • Vitamin B12 levels for patients on metformin 3, 1
  • Serum potassium levels for patients on ACE inhibitors, ARBs, or diuretics 3, 1

Age and Risk-Based Screening Documentation

• Record diabetes screening results for adults with BMI ≥25 kg/m² with risk factors 3
• Document yearly testing results for patients with prediabetes (A1C 5.7-6.4%) 3
• Record bone densitometry results for postmenopausal women and men age ≥50 years 3
• Document functional performance assessment for adults ≥65 years 3
• Record cognitive impairment screening results for older adults with risk factors 3

Preventive Health Counseling Documentation

• Document diet and nutrition guidance provided 3, 1
• Record physical activity recommendations discussed 3, 1
• Document tobacco cessation counseling provided 3, 1
• Record alcohol and substance use counseling provided 3, 1
• Document depression, anxiety, and disordered eating screening results 3, 1

Assessment and Plan Documentation

• Create a comprehensive problem list documenting all active and chronic conditions 1
• Develop and document a preventive care plan, including recommended vaccinations and schedule for future screening tests 1
• Document any referrals to specialists 1
• Record patient education materials provided 1

Common Pitfalls and How to Avoid Them

• Avoid focusing only on the presenting complaint - document findings from a complete examination to prevent missing potentially serious conditions 4
• Ensure documentation of medication allergies and adverse reactions to prevent future adverse events 2
• Document all medications taken over the previous 2 months, including over-the-counter and complementary/alternative therapies 2
• Record the date treatments were started, dose escalations, and when drugs were stopped 2
• Note any brand switches or medication errors 2