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What information is recorded during office visits?
Home » Healthcare Administration » Medical Records » What information is recorded during office visits?There are different types of office visits: well check-ups and yearly physical exams, in depth consultations for specific issues, re-checks to follow up on a previous consultation, and of course, your average, I feel-bad-and-need-to-see-a-doctor-visits. Generally speaking, the office visit is conducted in the following manner: the physician inquires about your chief complaint or the main reason why you are visiting a doctor. The physician will ask all sorts of information to understand the problem. He will also ask for a history of the present problem, which will include questions of how long the symptoms have been present and how severe the problem has been. The doctor will likely do a physical exam, including listening to the heart and lungs and palpating the abdominal cavity to see if there is any unusual tenderness or unexplained mass in the stomach, liver, etc. The doctor, at this point, may offer a diagnosis, or he or she may determine that further tests be conducted. The physician would make orders to the appropriate lab or clinic for the tests. Also, the physician may prescribe medicines to help heal the illness or control symptoms. All of the information obtained in the office visit is recorded in the person’s medical chart. This is done in several ways: Electronic medical records offer easy-to-use templates that make recording the information quick and easy. The doctor, for both paper and paperless charts, may make a quick recording in a small tape player detailing all the information from the visit. A transcriptionist will type out the recorded information and place it in the patient’s chart. At the end of each visit or at the end of the day, the doctor will make any further notes or annotations to make the record of the patient’s visit complete.
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