WHAT: RECOMMENDED FORMAT ON WHAT TO WRITE IN THE SYSTEM FOR PATIENT’S CONSULTATION

PURPOSE: CBAHI INSPECTION

Remarks Chief Complaint & Main Symptoms Significant Signs

Example for 1st visit of patient with Chronic Disease Significant signs examples:
(Hypertension)
 The patient is having/experiencing Epistaxis
“The patient came in due to: dizziness, trouble sleeping,
or Nose bleeding due to elevated blood
fatigue and confusion, headaches, weakness, increase
pressure
blood pressure, restlessness, scraping pain on neck, etc.”
 Patient is holding her/his chest during the
visit due to chest pain
Example: for follow-up Patient if condition has improved
 Urine sample shows blood during
“Patient came in for follow up consultation for diabetes investigation
(or other disease) or coming for follow up with improved
condition”

Note: If no improvement, indicate details.

PLEASE READ:

 A chief complaint is a statement, typically from the patient’s own words or verbatim.
 Significant signs are signs that a physician can see through the patient during visit.
 WHAT: RECOMMENDED FORMAT ON WHAT TO WRITE IN THE SYSTEM FOR PATIENT’S CONSULTATION
PURPOSE: CBAHI INSPECTION

Patient Education Notes

WHAT TO WRITE What to write:

>Advice drug frequency, side effect and drug
interaction was given
>Life-style modification such as diet and exercise
>Importance of follow-up visits
If the patient was advised of a measurable goals or plan of care,
the doctor should write:
“Patient is at her/his goals as per plan of care such as: managing
cholesterol, maintaining normal range of blood sugar, monitoring
blood pressure or maintaining ideal weight.”

Visit Details When to write:

Note progress of patient on follow-up or 2nd visit
What to Write Example
Physical examination:
 Patient’s Medical History
 HEENT:
 CHEST:
 CARDIAC: REMINDER:
 ABDOMEN:
 EXTREMITIES: THIS TYPE OF FORMAT
IS RECOMMENDED
SPECIALLY FOR THOSE
Care Plan
PATIENTS WHO HAVE
CHRONIC DISEASES,
“What to write Example” For patients with Asthma (SUCH AS ASTHMA,
For the next visit, the patient should: the doctor can write: DIABETES AND
 >Manage your cholesterol (under 200 mg/dl) HYPERTENSION)
>No night cough
 >blood sugar within normal range (less than 140 mg/dL (7.8 >No shortness of breath OTHER CONDITION
mmol/L) during exercise AND COMPLAINS.
 >Journal of blood pressure monitoring >less than 2 rescuer
 >Maintain a healthy weight (indicate ideal weight for patient) medication per week
 >Daily exercise of 30 minutes



 WHAT: RECOMMENDED FORMAT ON WHAT TO WRITE IN THE SYSTEM FOR PATIENT’S CONSULTATION
PURPOSE: CBAHI INSPECTION

Notice:
IMPORTANT TO FILL IN DOSAGE, ROUTE, FREQUENCY,
START DATE, END DATE & DURATION