ABSTRACT
History Accurate and complete health record documentation in ambulatory care is critical to the quality of the care provided. A medical record should tell an allinclusive story of a patient’s history and care. ’e basic elements must include patient demographics, reason for the visit, list of past and current problems, results of physical exam, results of diagnostic testing, treatments, plans of care, and follow-up care. For a list of core documentation requirements, refer to Table 9.1.
