The following is an example of a blank visit record formerly used for the documentation of emergency care at HCMC. I present it here to give a visual outline of what should be included in the record of a properly documented Emergency Medicine encounter. All patients need a HPI, ROS, Past medical family and social history, & a physical examination documented. Additionally any procedures done during the patients care should be documented. It is also important to document a differential diagnosis along with a care plan. Furthermore many patients will be continually reassessed during their care. Patients with asthma are prime examples. Proper care and documentation of such patients require that these interval assessments be documented in their visit record. Currently HCMC uses EPIC (our computerized medical record) to record patient care by the RNs and MDs. Each piece of the record is entered on its own "smart form" which will be demonstrated during orientation.
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