Read Workshop - Office Visit Chart Extraction Instrument
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2READ Workshop - OFFICE VISIT CHART EXTRACTION INSTRUMENT
Date: July 1, 2009
This questionnaire will assist you in identifying the essential components of an outpatient note. Please mark
the appropriate boxes based on your assessment of the note provided. Add any additional comments in the
space provided.
I. Basic Elements
The following basic elements are present:
Yes
No
Date
Time
Chief complaint or Reason for visit
Signature
II. Subjective
The history portion of the note contains
Yes
No
Incomplete
a complete and directed HPI based on the chief complaint.
a list of agenda items (e.g., patient & provider concerns).
a discussion of relevant chronic medical conditions.
an updated list of medications.
III. Objective
The physical exam contains documentation of
Yes
No
Incomplete
a blood pressure.
a weight.
a body-mass index (BMI).
a description of patient’s general appearance.
findings (positive or negative) pertinent to history elements.
IV. Data
The note contains updated information on
Yes
No
Incomplete
recent laboratory data (or documentation that none exists).
diagnostic studies performed at that visit (e.g., U/A, EKG).
Office Visit Chart Extraction Instrument p.
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