Providers can enter various values for use in the EMR - General Medical Observation section.
General medical observations refer to comments in the chart describing the patient's overall systemic health or general constitution. Commonly we see notes such as:
•Patient states she is healthy,
•Patient states DM is well controlled,
•Patient complains of recent onset of cold symptoms.
•Without detailed instructions regarding documentation of the general medical observation, we believe there is some latitude in interpreting this requirement.
