Table 4.

Description of Clinical Documentation Categories

Clinical documentation category	Definition
Assessment and diagnosis	Provider’s clinical diagnoses, decision-making, and treatment plan
Collect clinical encounter reason	The patient’s chief complaint
Collect vitals	Standard vital signs, such as heart rate, blood pressure, and respiratory rate; includes documentation of adding, removing, or reviewing information
Conduct physical exam	Provider’s physical exam, to include abnormal, relevant normal, and pertinent negative findings
Conduct procedure	In-office bedside procedures, such as minor dermatologic or gynecologic procedures
Conduct review of systems	Standard organ-specific system review, emphasizing pertinent negatives
Confidential information	HIPAA-protected, patient-specific identifiers and patient-specified confidential information, such as HIV status; includes documentation of adding, removing, or reviewing information
Creating or sending out orders	Implementation of the treatment plan, including patient instructions
History of present illness	Narrative about the patient’s chief complaint, including pertinent positives and negatives; includes documentation of adding, removing, or reviewing information
Interpret incoming clinical data	Interpretation of the results of tests, other notes, and so on
Medication list	Prescription and nonprescription medications the patient is taking or has taken; includes documentation of adding, removing, or reviewing information
Problem list	List of diagnoses the patient has or has had; includes documentation of adding, removing, or reviewing information
Review and discuss documents	Discussion of external documents with the patient
Sign-off or close encounter	Closing the encounter
Social history	Patient’s lifestyle practices (e.g., diet, exercise) and habits (e.g., smoking, alcohol consumption); includes documentation of adding, removing, or reviewing information