{"id":1317,"date":"2023-12-06T13:38:00","date_gmt":"2023-12-06T21:38:00","guid":{"rendered":"https:\/\/www.cdcr.ca.gov\/hcdom\/?post_type=dom&#038;p=1317"},"modified":"2026-10-12T13:07:05","modified_gmt":"2026-10-12T20:07:05","slug":"1-4-2-4-medical-provider-documentation-expectations","status":"publish","type":"dom","link":"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-1-health-care-governance-and-administration\/article-4-2-professional-workforce-medical-services\/1-4-2-4-medical-provider-documentation-expectations\/","title":{"rendered":"1.4.2.4 Medical Provider Documentation Expectations"},"content":{"rendered":"\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Purpose<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>To ensure that medical providers document all medical encounters in a complete and timely manner. The health record is a medical legal document and where every effort shall be made for an accurate and timely record of the patient\u2019s condition, progress, and treatment plans.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Medical providers shall adhere to the following documentation requirements:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Content and format of the health record shall be uniform, and only approved California Department of Corrections and Rehabilitation (CDCR) documentation formats used.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>For patient safety reasons, abbreviations, acronyms, and symbols shall be used only when they are on the CCHCS approved list of abbreviations and symbols.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>All documentation shall be entered electronically, except during Electronic Health Record System (EHRS) downtime procedures or when a particular process requires paper documentation. All paper documentation shall be legible.  All documentation shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Be clear, concise, objective, reflect factual information, and shall serve to identify the patient, support and justify the provider\u2019s medical decision making regarding the patient&#8217;s diagnosis, care, treatment, and services provided, as well as document the course of treatment and results.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Be courteous to other individuals and shall not include copies of administrative memos, administrative directives or emails, non-clinical information, or other information which is unrelated to the patient\u2019s care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Include the name and classification of the Chaperone present for an examination involving genitalia, rectum, or breast, or upon patient or provider request.  If an examination proceeds without a Chaperone when required, documentation shall include the rationale the examination proceeded without a Chaperone.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Include other relevant information to the encounter including, but not limited to, the presence of medical professionals in training, how informed consent was obtained (verbal and written), as well as patient education provided.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>When using templates, care shall be taken to ensure the information entered is accurate.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Timeliness of documentation<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Documentation shall be entered in the patient\u2019s medical record whenever the patient is assessed, evaluated, given education during a medical encounter, or receives orders for diagnostic testing, medications or other treatment.  This includes, but is not limited to, in-person or telemedicine medical encounters, inpatient admission and rounding encounters, Triage and Treatment Area (TTA) encounters, on-call clinical decision making and in clinical co-consultations with a nurse.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Documentation shall be completed within the following timeframes:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>For in-person or telemedicine outpatient medical encounters, documentation shall be completed as soon as possible, preferably on the day of the encounter and no later than the next calendar day.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>For inpatient rounding and on-site after hours medical encounters, documentation shall be completed the day of the encounter but no later than the next calendar day.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>For on-call medical encounters done remotely, documentation shall be completed in the EHRS by the end of the next business day. <\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Co-consultations, documentation is expected to be completed the day of the appointment but no later than the next calendar day. While the primary care provider (PCP) is not required to see the patient for all co-consultations, after discussing with the Registered Nurse, the PCP shall use clinical judgment to determine whether they too should see the patient before completing the co-consultation.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>In rare circumstances where timeframe extensions are needed, written supervisor approval is required.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Late Entry<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>While not the accepted standard, late entries shall be completed as soon as it becomes apparent of the missed medical encounter documentation. There is no time limit for completing a late entry; however, the longer the time lapse, the less reliable the entry becomes. When a pertinent medical record entry was missed or not written in a timely matter, the provider shall follow these requirements:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identify the new entry as a &#8220;late entry.&#8221;<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identify or refer to the medical encounter date and circumstance for which the late entry is written.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Enter the current date and time.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Sign the entry.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>In the EHRS the date, time, and author of an addendum is noted automatically, and the addendum is flagged as part of the original note.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identification of Documentation <\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>To allow clinical information to be located easily within the EHRS, providers shall ensure that their documentation is made in the appropriate area of the EHRS and that entries are labeled correctly and with as much specificity as possible.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Medical notes in the Documentation section of the EHRS are each assigned a note &#8220;Type&#8221; and a &#8220;Title&#8221;.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The note &#8220;Type&#8221; is selected using a drop-down menu and includes choices &#8220;History and Physical&#8221;, \u201cOutpatient Progress Note&#8221;, \u201cInpatient Progress Note&#8221;, \u201cPhone Message\/Call\u201d and \u201cProcedure Note\u201d.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The note &#8220;Title&#8221; is populated by choosing a &#8220;Note Template&#8221; from the selections offered. There are several choices of note templates that can be used including \u201cAdmission H&amp;P\u201d, \u201cOffice Visit Note\u201d, \u201cProgress\/SOAP note\u201d, \u201cProcedure Note\u201d, and \u201cFree Text Note\u201d. The note &#8220;Title&#8221; can also be entered as free text and customized.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensure the note \u201cType\u201d is correct to assist others in navigating the health record. For example: Note type &#8220;Outpatient Progress Note&#8221; would be used for Chronic Care and Episodic Care, while note type &#8220;Procedure Note&#8221; would be used when documenting a medical procedure. <\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Refer to Appendix 1, Examples of Encounter\/Note Types, Titles and Templates for examples.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>On \u2013 Call Documentation<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The on-site call duties shall be documented utilizing note types \u201cTTA Progress Note\u201d or \u201cInpatient Progress Note\u201d for rounding in inpatient areas.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Phone on-call duties shall be documented using the \u201cPhone Message\/Call\u201d note type.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The medical provider shall record the assessment (or verbal assessment received from the Nursing staff), the actions taken, and the medical rationale for the actions taken. The on-call provider ensures any necessary follow up is ordered with the PCP.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Other Documentation Expectations:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Providers using voice-activated documentation systems (e.g., Dragon Dictation) shall review the note, correct errors and omissions and sign the note to authenticate its accuracy. A blanket disclaimer regarding possible dictation errors does not absolve a provider from proofreading their dictated notes for accuracy and completeness.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Auto-populating and copy and paste guidelines<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Both functionalities are available in the health record and have the potential to save time. However, these features are also easily abused and may create patient safety risks when auto-populated or copied and pasted information is not carefully reviewed.  Medical providers shall adhere to the following expectations as it relates to auto-populated and copied and pasted information:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Carefully review information to ensure up-to-date, accurate, and belongs to the correct patient.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Keep to a minimum when used.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensure that the information applies to the current visit, that applicable changes are made to variable data, and that any new information is recorded.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Copying from another provider\u2019s entry: If a provider copies all or part of an entry made by another provider\u2019s source documentation, the provider using the copied entry becomes responsible for the accuracy of the other provider\u2019s source document. The source author\u2019s name should be included.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Copying test results and data: If a provider copies and pastes test results into an encounter note, the provider is responsible for ensuring the copied data is relevant and accurate.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Diagnostic Tests and Labs <\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Providers shall indicate that they have reviewed and addressed diagnostic reports by initialing and dating each hard copy report or by electronically endorsing each report through the approved EHRS workflows. Refer to the HCDOM, Sections <a href=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-3-health-care-operations\/article-1-complete-care-model\/3-1-13-medical-imaging-services\/\" data-type=\"link\" data-id=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-3-health-care-operations\/article-1-complete-care-model\/3-1-13-medical-imaging-services\/\">3.1.13, Medical Imaging Services<\/a>, and <a href=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-3-health-care-operations\/article-1-complete-care-model\/3-1-14-laboratory-services\/\" data-type=\"link\" data-id=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-3-health-care-operations\/article-1-complete-care-model\/3-1-14-laboratory-services\/\">3.1.14, Laboratory Services<\/a>.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Per the above referenced policies in Section (b)(1)(D)(3), the provider creates a patient letter when indicated, which is sent to the patient.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>If clinically indicated the provider shall create a plan of care that addresses any abnormal test results and document this plan in the health record.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Providers shall review and endorse consultation reports within five calendar days of the date of receipt by the institution.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Telephone and verbal orders shall be reviewed and signed within 48 hours excluding weekends and holidays. Orders placed weekends or holidays shall be reviewed and signed by the end of the next business day.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Providers shall document validation that effective communication was provided when required by policy. Refer to the HCDOM, Section <a href=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-2-patients-entitlements-and-responsibilities\/article-1-provision-of-health-care-services\/2-1-2-effective-communication-documentation\/\">2.1.2, Effective Communication Documentation<\/a>.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendices<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Appendix 1: Examples of Encounter\/Note Types, Titles and Templates<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>References<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Business and Professions Code, Division 2, Chapter 5, Article 12, Section 2262<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Business and Professions Code, Division 2, Chapter 5, Article 12, Section 2266 <\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health and Safety Code, Division 106, Part 1, Chapter 1, Section 123149.5<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p><a href=\"https:\/\/cdcr.sharepoint.com\/sites\/cchcs_lifeline_rmb\/Memoranda\/Forms\/AllItems.aspx?id=%2Fsites%2Fcchcs%5Flifeline%5Frmb%2FMemoranda%2FMedical%20Provider%20Rounding%20and%20Documentation%20%2D%20Specialized%20Health%20Care%20Housing%2Epdf&amp;parent=%2Fsites%2Fcchcs%5Flifeline%5Frmb%2FMemoranda\">Medical Provider Rounding and Documentation \u2013 Specialized Health Care Housing Memorandum June 27, 2022<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 2, Article 1, Section 2.1.2, Effective Communication Documentation<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.5, Scheduling and Access to Care<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.10, Specialized Health Care Housing<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.13, Medical Imaging Services<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.14, Laboratory Services<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Policy Control<\/strong><br>Executive Sponsor:  Deputy Director, Medical Services<br>Effective: 05\/16\/2023<br>Revised: 11\/22\/2023, 10\/12\/2026<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 1:  Examples of Encounter\/Note Types, Titles and Templates<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>Encounter Type<\/strong><\/td><td><strong>EHRS Note Type<\/strong><\/td><td><strong>Title (designated by Note Template chosen)<\/strong><\/td><\/tr><tr><td>Chronic Care Visit<\/td><td>Outpatient Progress Note<\/td><td>Multiple Note Templates can be chosen including:<br>\u2219 Office Visit Note<br>\u2219 Progress\/SOAP note<br>\u2219 Free Text Note<br>&nbsp;<br>For additional specificity providers can add detail to the title such as:<br>\u201cOffice Visit Note Chronic Care DM\u201d<br>&nbsp;<br>The Title can be entered completed as free text as well, such as:<br>\u201cCCP \u2013 MAT F\/U, HTN\u201d<\/td><\/tr><tr><td>Medical Episodic Visit 7362 F\/U<\/td><td>Outpatient Progress Note<\/td><td>Multiple Note Templates as above can be chosen.<br>&nbsp;<br>Can add or free text additional information such as:<br>\u201cProgress\/SOAP note abnormal lab follow \u2013 up\u201d.<br>&nbsp;<br>The Title can be entered completed as free text as well, such as:<br>\u201c7362 F\/U rash and knee pain\u201d.<\/td><\/tr><tr><td>Co \u2013 Consultation<\/td><td>Outpatient Progress Note<\/td><td>Multiple Note Templates as above can be chosen.<br>&nbsp;<br>\u201cFree text note\u201d and Title: \u201cCo \u2013 Consult 7362 rash\u201d<br>ii.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; PCP adds addendum to the Nursing documentation and co \u2013 signs the Nursing note.<\/td><\/tr><tr><td>Specialist phone calls\/ emails<br>Family Communication<\/td><td>Phone Message \/ Call<\/td><td>Typically, \u201cFree Text Note\u201d template is used.<br>&nbsp;<br>Additional detail can be added to Title such as:<br>Free Text Note Specialist correspondence Free Text Note Family Communication<\/td><\/tr><tr><td>On-Call duties done on site<\/td><td>TTA Progress Note or Inpatient Progress Note<\/td><td>Multiple Note Templates can be chosen including:<br>\u2219 Office Visit Note<br>\u2219 Progress\/SOAP note<br>\u2219 Free Text Note<\/td><\/tr><tr><td>On-Call duties done remotely<\/td><td>Phone Message \/ Call<\/td><td>Note Templates often used is Free Text Note<br>&nbsp;<br>\u201cDot-phrase\u201d available to pull in some information: [.oncall]<\/td><\/tr><tr><td>Procedure documentation<\/td><td>Procedure Note<\/td><td>Note Template \u201cProcedure Note\u201d<br>&nbsp;<br>Can add Title detail such as: Procedure Note Toenail removal<\/td><\/tr><tr><td>TTA visit<\/td><td>TTA Progress Note<\/td><td>Multiple Note Templates can be chosen including:<br>\u2219 Office Visit Note<br>\u2219 Progress\/SOAP note<br>\u2219 Free Text Note<br>&nbsp;<br>Additional detail can be added to Title such as: Free Text Note TTA Abdomen pain<\/td><\/tr><tr><td>Inpatient documentation (including CTC, PIP, OHU)<\/td><td>Inpatient Progress Note<\/td><td>Multiple Note Templates can be chosen including:<br>\u2219 Office Visit Note<br>\u2219 Progress\/SOAP note<br>\u2219 Free Text Note<br>&nbsp;<br>Additional detail can be added to Title such as: \u201cProgress\/SOAP note CTC 7 day PCP\u201d<br>\u201cFree Text Note PIP 30 day PCP\u201d<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong><strong>Policy Control<\/strong><br><\/strong>Executive Sponsor:  Deputy Director, Medical Services<br>Effective: 05\/16\/2023<br>Revised: 11\/22\/2023, 10\/12\/2026<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t","protected":false},"parent":255,"template":"","class_list":["post-1317","dom","type-dom","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>1.4.2.4 Medical Provider Documentation Expectations - Health Care Department Operations Manual (HCDOM)<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"1.4.2.4 Medical Provider Documentation Expectations - Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"og:url\" 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