Q: Our organization provides primary care services and we are surveyed under the CAMAC. What medical record documentation is required for an initial visit?
A: Standard PC.2.20 requires that organizations define what data and information must be gathered during the initial assessment. This should include the following, as relevant to the patient and organization-specific care, treatment, and services provided:
- Physical assessment
- Psychological assessment
- Social assessment
- Nutrition and hydration status
- Functional status
- Pain assessment (PC.8.10) and
- For patients receiving end-of-life care, the social, spiritual, and cultural variables that influence the perceptions and expressions of grief by the patient, family members, or significant others.
From a policy and procedure standpoint, organizations must define for both initial and reassessment:
- The scope of assessment and reassessment activities that can be conducted by each clinical discipline (governed by scope of practice, state licensure laws, applicable regulations, or certification of the discipline)
- Content of the assessment
- If applicable, specialized assessment and reassessment information for various populations served
- Timeframes for completing the initial assessment (PC.2.120)
- When and how a reassessment is conducted (PC.2.150) and
- Criteria for when an additional or more in-depth assessment is required.