When it comes to medical documentation, CHEDDAR is a mnemonic that aids healthcare providers in efficiently and effectively documenting patient encounters. It stands for Chief Complaint, History of Presenting Illness, Examination, Details, Drugs and Dosages, Assessment, and Return Visit Information or Referral.
Chief Complaint
The chief complaint is the primary reason for the patient’s visit, expressed in their own words. It helps set the direction for the rest of the encounter, guiding subsequent questioning and examination.
History of Presenting Illness
The history of presenting illness involves gathering information about the current issue, including its onset, duration, severity, aggravating and alleviating factors, and associated symptoms. This helps in understanding the context of the patient’s complaint.
Examination
The examination component involves the physical assessment of the patient, including vital signs, organ systems examination, and any specific assessments relevant to the chief complaint. This hands-on evaluation provides crucial diagnostic information.
Details
Details encompass any additional information relevant to the patient encounter, such as past medical history, surgical history, family history, social history, and allergies. These details contribute to a comprehensive understanding of the patient’s health status.
Drugs and Dosages
Documenting drugs and dosages involves recording the medications the patient is currently taking, including prescription medications, over-the-counter drugs, supplements, and their respective dosages. This information aids in treatment planning and avoids potential drug interactions.
Assessment
The assessment section includes the healthcare provider’s evaluation and diagnosis based on the gathered information from the patient’s history, examination, and any additional tests or investigations. It outlines the working diagnosis and differential diagnoses.
Return Visit Information or Referral
Finally, the return visit information or referral provides instructions for follow-up care, such as scheduling a revisit for further evaluation, referrals to specialists, or additional diagnostic tests. This ensures continuity of care and appropriate management of the patient’s health concerns.
