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INTERNISTS PERCEPTIONS REGARDING PATIENT ACCESS TO PROGRESS NOTESby Alfredo Almerares, MD A THESISPresented to the Department of Medical Informatics & Clinical Epidemiology and the Oregon Health &
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Review the patient's medical history thoroughly.
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Assess the patient's current health status and symptoms.
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Identify the specific areas of concern relevant to the patient.
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Gather data from diagnostic tests, if applicable.
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Document observations and thoughts clearly.
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Consider the patient's perspectives and preferences.
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Internists perceive patients as individuals requiring comprehensive and continuous care, focusing on both physical and mental health, while also considering their unique backgrounds and circumstances.
Internists themselves or their designated administrative staff are required to file perceptions regarding patients.
To fill out internists perceptions regarding patients, practitioners should document observations and assessments regarding patient health, preferences, and any concerns, usually in a standardized format or electronic medical record.
The purpose is to facilitate better patient care by documenting insights into patient health, enhancing communication, and informing treatment plans.
Information must include patient demographics, medical history, current symptoms, treatment responses, personal preferences, and any psychosocial factors that may affect care.
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