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Content of Medical Record

12. Consider adopting the S.O.A.P. formula or similar system for record keeping. This

will ensure that all elements of the patient’s visit are recorded.

13. Establish ways to improve legibility. This may be accomplished by means of

typed or printed notes (write slower, more deliberately and use a consistent entry

model, i.e. S.O.A.P. or similar format) or through the use of handheld or voice

activated dictation systems. Consider implementing an Electronic Medical Record.

14. Utilize and maintain Pediatric Growth Charts. Consider gender specific growth

charts to capture height, weight and head circumferences for children to the age

of two years.

15. Recommend selectively the consistent use and maintenance of a Cumulative

Patient Profile to assist in providing continuity of care.

16. Develop a medication flow sheet to include a full list of medications prescribed,

duration of and amount of prescriptions.

17. Consider taking measures to organize chart contents to provide easy

identification and access to patient information.

18. Consider the selective use of laboratory flow sheets which would allow a quick

and a complete overview of lab results at a glance.

19. Initial, or otherwise indicate, that all incoming lab results/reports have been seen

and any appropriate follow up arranged.

20. PEP encourages the selective use of flow sheets to improve the quality of patient

care and clinical practice.

21. Document preventive care or emphasize such care in the medical records,

particularly for chronic cases.

22. Provide more detailed documentation regarding management of chronic care.

23. Provide more in-depth medical history, especially when it relates to complete

or general assessments. This would reflect appropriate medical care. Particular

attention should be given to family history, social history, systemic review, and

significant past medical and surgical history.

24. Record all significant telephone calls in the charts including any telephone advice

given or action taken. Have charts pulled to go along with any phone call

messages and/or prescription refill requests in order to permit recording of any


25. Recommend use and comprehensive completion of Saskatchewan Prenatal


26. Always measure and record the symphysis to fundal heights on the standard

antenatal record.

27. Indicate negative findings as well as positive information in the medical record.

28. When medical practice deviates from the norm, indicate on the medical record

reasons for such practice (e.g. non-compliant patient).

29. Consider documentation of date checks on pharmaceutical drug samples and

emergency crash kit drugs on a regular interval.

30. Incorporate use of clinical practice guideline flowsheets, especially for chronic

patients such as diabetics, hypertensives and coronary heart disease patients, to

ensure consistency and expediency in monitoring of risk factors.