Patients with Chronic Conditions

Patients with Chronic Conditions

For patients with chronic conditions, such as diabetes
mellitus, it is often useful to have flow sheets that
allow the physician to record important clinical information
about the patient’s management over long
periods of time. Flow sheets permit the physician to
see trends that enhance his or her ability to identify
the appropriate treatment. Flow sheets will, of necessity,
deal only with one disease. The CPP and the
progress notes will be the principal information used
to ensure comprehensive care.

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General Assessments

General Assessments

The general assessment is a comprehensive examination
conducted to establish a diagnosis, ascertain target
organ involvement, and develop an investigative
and treatment plan for a specific medical condition.
The physical examination should include all body
parts and systems relevant to the condition at issue
(e.g., if the presenting problem is chest pain, the
physician would examine the body parts that might
be involved, but might not conduct a pelvic or rectal
examination).
This type of encounter should be recorded as a general
assessment. Again, the CPP should be used to
review and update the patient’s medical history, family
and social history, ongoing health concerns or problem
list, immunizations, allergies, and medications.
The record of the visit should reflect all of the elements
of the physical examination.

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