Annual wellness visits or Prospective Program health assessments are a great opportunity to update and reconcile your patients’ medical records.

Consistent, complete, and accurate documentation, including an updated health history, supports quality and continuity of care. Past medical history and problem and medication lists can provide insights into your patient’s health status. However, conflicting, or inaccurate information can affect the validity of the medical record.

Updating information in your EMR

The following are suggestions to maintain information that accurately reflects the health status of your patients. If your electronic medical record (EMR) has different structures for recording this information, you can easily adapt these suggestions to fit your needs.

• Past medical history – Resolved conditions that have been treated and are no longer active, including previous surgeries and infectious processes.
o Document dates of occurrence, resolution, or surgery.
o Verify any self-reported conditions.

• Current problems – Conditions for which the patient is seeking or receiving treatment and other issues that may impact care.
o Revise conditions that have evolved to a different or more specific diagnosis.
o Group related problems together to avoid similar but conflicting diagnoses and combine when appropriate.
o Document date of onset.
o Move to past medical history when no longer current.

• Medications
o Document date of initial prescription.
o Document dosage and each time the dosage is revised.
o Document date of discontinuation.

Important reminders

• Continual review and revision of the lists within the medical record remain the best practice.
• All reported diagnoses should be completely and accurately documented with subjective information and objective data. They should include an assessment and a treatment plan.
• Medical record lists do not provide complete support for reporting a diagnosis.