1.12 Documentation

Documentation

  • Written documentation is necessary in a patient’s physical examination.
  • The patient’s medical history should be documented in writing.
  • Use of anatomical diagrams also may be helpful.
  • The documentation should state what the examination findings were.
  • Make certain the documentation is legible.
    • Choose a format:
      • Dictated, printed, check box with pre-printed options, electronic medical record (EMR)-based form, etc.
  • Document who is relaying history (patient, caregiver, or someone else).
‌Office on Violence Against Women. (2013)