The documentation relative to a patient problem that is correct and includes all necessary legal requirements is:
a. 10:00 AM Dr. Jones notified of one-inch circular red macular rash on patient's left cheek. Area is inflamed, and patient complains of itching. Left order for calamine lotion BID.
b. MD called R/T to rash on left cheek. Left orders.
c. 10 Dr. Jones L/O for calamine lotion for rash on cheek.
d. 10:00 AM Dr Jones notified of one-inch circular red macular rash on patient's left cheek. Area is inflamed, and patient complains of itching. Left orders.
A
The legal requirements for documentation include the time, person notified, a description of the complaint, the result of the call, and signature.
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