What are the essential components of a complete outpatient visit note?

Essential Components of a Complete Outpatient Visit Note

A complete outpatient visit note must include the History of Present Illness (HPI), Assessment, and Plan (A&P) as the most critical sections, with additional required elements including medical history, physical examination findings, and documentation of patient identification, date/time, and provider authentication. 1, 2, 3

Core Documentation Elements

Patient Identification and Administrative Data

• Document date and time of visit, patient name and identification number, and provider name with authentication 2
• Include total encounter time if billing for time-based services 2

Medical History Components

Initial Visit Requirements:

• Characteristics of diabetes onset (age, presenting symptoms) and family history of diabetes or autoimmune disorders in first-degree relatives 1
• Complete medication list including current doses, medication-taking behavior, and any rationing of medications or medical equipment 1
• Tobacco, alcohol, and substance use history 1
• Vaccination history and needs 1
• Previous growth records and pubertal development in children/adolescents 1
• Lifestyle, cultural, psychosocial, educational, and economic factors that might influence diabetes management 1

Follow-Up Visit Requirements:

• Review of previous treatment plans and response 1
• Changes in medical or family history since last visit 1
• Eating patterns, weight history, and physical activity behaviors 1
• Medication intolerance or side effects 1
• Glucose monitoring results and data use (meter/CGM) 1
• Review insulin pump settings and use, connected pen and glucose data 1

Annual Visit Requirements:

• Frequency, cause, and severity of past hospitalizations 1
• Assessment of macrovascular and microvascular complications 1
• Last dental visit 1
• Disability assessment and use of assistive devices (physical, cognitive, vision, auditory, history of fractures) 1
• Current medication plan and complementary/alternative medicine use 1

Physical Examination Findings

Required at Every Initial Visit:

• Height, weight, and BMI calculation; growth/pubertal development in children and adolescents 1
• Blood pressure determination 1
• Orthostatic blood pressure measures when autonomic neuropathy is suspected 1
• Fundoscopic examination (or referral to eye specialist) 1
• Thyroid palpation 1
• Skin examination including acanthosis nigricans, insulin injection sites, and lipodystrophy 1

Comprehensive Foot Examination (Annual):

• Visual inspection for skin integrity, callous formation, foot deformity, ulcers, and toenail abnormalities 1
• Pedal pulse assessment to screen for peripheral arterial disease (refer for ankle-brachial index if diminished) 1
• Temperature, vibration or pinprick sensation testing 1
• 10-gram monofilament examination 1

Assessment and Plan Section

This is the most important section that physicians refer to first and should contain: 3

• Clear diagnostic assessment with supporting clinical reasoning 3
• Specific treatment plan including medication changes, dosing instructions, and rationale 3
• Follow-up testing ordered with specific timeframes 3
• Referrals to specialists with indication 3
• Patient education provided and counseling on lifestyle modifications 1

Review of Systems

While physicians often view ROS as superfluous, it must be documented when it contains relevant information not captured in the HPI 3

• Gastrointestinal symptoms (including celiac disease symptoms) 1
• Symptoms of other endocrine disorders (hypothyroidism, Addison's disease) 1
• Cardiovascular symptoms 1
• Neurological symptoms 1

Social Determinants and Psychosocial Screening

Document social supports and barriers to care:

• Existing social supports and surrogate decision maker 1
• Social determinants of health including food security, housing stability, transportation access, financial security, and community safety 1
• Daily routine and environment, including school/work schedules and ability to engage in diabetes self-management 1

Mental Health Screening:

• Screen for depression, anxiety, diabetes distress, and fear of hypoglycemia using validated tools 1
• Screen for disordered eating patterns when appropriate 1
• Consider assessment for cognitive performance in older adults 1

Common Pitfalls to Avoid

Do not rely on heavily templated notes that patients perceive as inaccurate - patients in safety-net settings specifically identified templated content as problematic and inaccurate 4

Do not place Assessment and Plan at the bottom of the note - physicians consistently review A&P first, and placing it at the bottom increases cognitive load and inefficiency 3

Do not omit the History of Present Illness - this section is identified as one of the three most important components (along with A&P) and is recorded most completely at 71% accuracy 3, 5

Do not skip documentation of negative findings in the foot examination - this is the most commonly neglected component that leads to preventable complications 6

Avoid excessive medical jargon - 29% of patients report notes contain too much jargon, which undermines the note's utility for patient engagement and diagnostic accuracy 4

Document all elicited information - only 59% of information discussed verbally appears in medical records, with non-present illness history recorded at only 29% 5