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Documentation

Careful documentation is particularly important when PEs are practicing medicine under supervision, but it is not necessary or desirable to document every positive and negative physical finding. Such charts will be hard to read and are unlikely to be reviewed completely by the supervising physician. The important items to document are the subjective and objective findings that support the diagnosis under the protocol, the decision-specific assessment, and the treatment and instructions authorized under the protocol. Using the example of strep throat, an adequate visit entry might read as follows:

S:
sore throat x 3 days

O:
TMs clear, chest clear, throat red, no adenopathy, rapid strep +

A:
strep pharyngitis

P:
Penicillin V K 250 mg q.i.d. x 10--dispensed Tylenol, rest, liquids RTC 2 weeks for recheck, sooner if problems

This chart entry, made in a timely fashion and legibly, provides all the necessary documentation for this encounter. It documents the trigger for the protocol and that the protocol was followed in testing, treatment, and follow-up. The protocol itself will provide the additional information to flesh out the chart note.


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