Emergency care is required if a need arises that you just cannot wait for it to be addressed. It has to be addressed now. For this reason, we are asking the patient’s for due diligence as to whether their case is indeed an emergency or not.

The practitioner will gather in their notes how it began, how and why it evolved, how it came to a conclusion, and where it needs to go from here. It will tell a story that you can easily follow. The practitioner must document the encounter as if someone else will be taking over for them. Qualities that are essential to maintaining high quality medical records include completeness and accuracy in addition to conciseness and organization.

  • Completeness and Accuracy. A practitioner note must convey the pertinent details of your encounter and subsequent plan of care without including extraneous information. You will appreciate what is included in their written documentation should someone else take over for them.

  • Conciseness and Organization. By effectively organizing your note, the practitioner will achieve conciseness and be able to meet the expectations of other health professionals reading your notes. The emphasis is on capturing the relevant details of your condition.

The assessment or plan is arguably the most important part of the entire session as it displays the practitioner’s reasoning about your situation. For example, what the practitioner thinks may be going on with you and what they’re going to do about it.

After the initial questionnaire, the practitioner will gather up all their thoughts and proceed with care and expertise. Upon treating you, you may be asked to continue to see the practitioner or in conjunction with another practitioner.