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- Standardised documentation of physical examination, laboratory findings, and diabetes complications in a DMP-form once a year.
There are currently no evidence-based standards for best practice concerning adequacy of documentation of physical examination findings for Wellington Hospital, neither are there any clinical guidelines derived from expert opinion.
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A structured encounter form resulted in significant improvement in documentation of most aspects of well-child care by family practice residents, including developmental assessment, safety and nutrition counseling, and measurement of growth, but not of physical examination [ 17].
The remainder of physical examination was unremarkable.
Results of physical examination were unremarkable.
Rest of physical examination was normal.
In nearly half of the medical records, there was no documentation of history, physical examination, presenting problem and /or diagnosis.
Broadly speaking, art historians determine the attribution of a painting in two ways: historical documentation or physical examination.
A number of records had only the presenting problem or diagnosis written, with no documentation of history or physical examination.
The GP uses the standardised case report form (CRF-HA) for documentation of history and physical examination.
The positive findings are however not universal, with poor documentation of history and physical examination reported at a remote clinic in the 1970s [ 60], and with PAs being rated less favourably on all measures to monitor patients with diabetes and their patients less likely to achieve targets for disease control in 2002 [ 79].
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