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Basic Patient Information

The most important information is the basic patient data. The chart must contain enough information for a physician unfamiliar with the patient to provide appropriate care. This should include physiological information, therapeutic information, and any special patient characteristics such as allergies or handicaps. This information should be summarized on a cover sheet. There are several acceptable styles for providing this summary, but they share an emphasis on rapid identification of abnormal findings, the recording of problems that will require attention on future visits, and a way to ensure that the physician is notified if the patient misses a follow-up visit.

In clinics with several physicians, the demands on the medical record begin to resemble those of a hospital medical record. All of the physicians in the group must keep records in the same format, record enough information to allow any other physician in the group to treat the patient, and identify patient problems with great specificity to ensure continuity of care.

Multiphysician clinics create the opportunity for patient problems to be ignored through shared authority for patient care. As with hospital-based care, there must be one physician in charge of the patient's overall care, and the chart must identify this physician. The chart must also be returned to this physician for review whenever the patient is treated by another member of the clinic group. This review allows the primary physician to reconcile the care of the other providers. If there are problems, the patient can be contacted. If there are no problems, the reviewing physician can add whatever notes are necessary to ensure that the next physician to see that patient has the proper information.


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