Implementation: Paper Forms II
Implementation: Paper Forms II
- Each clinic has to arrive at consensus on
- Forms
- Coded clinic data
- Problem list vocabulary
Endocrine Visit Dictation Guidelines
1. Medical Record #
3. Patient's last name,
first name
4. Date of Birth
5. Presenting Diagnosis
6. Date of Visit
7. Date of Dictation
8. Referring Provider
9. Copies to
10. HPI/Interval History
11. Medications
12. Past Medical History
13. Review of Systems
14. Family History
15. Mother's Ht (measured)
16. Father's Ht (measured)
17. Height
18. Weight
19. Blood Pressure
10. Pulse
21. Lower Segment
22. Arm Span
23. Tanner Breast
24. Tanner Pubic Hair
25. L testicle (length x width)
26. R testicle (length x width)
27. Penile stretched length
28. Mid shaft diameter
29. Bone age (day of visit)
30. Physical exam
31. Labs (prior to visit)
32. Impression
34. Studies Ordered
35. Disposition
35. Primary signatory (fellow)
36. Secondary signatory
(attending)
Dictate items in order of numbering.
Bold faced items
must be completed for a dictation to be transcribed.
Before completing the dictation determine all the problems
on the Problem List sheet which are applicable to the patient
and read off the corresponding problems numbers at the end
of the transcription.
Shorter dictations are better.
They are more likely to be
read by the referring provider and minimize the use of
Division resources. HPI is where dictations tend to be too
long.