Get Dhhs 4059: Patient Visit Record - Nc Division Of Public Health - Publichealth Nc 2020-2025

Filling out the DHHS 4059: Patient Visit Record is an essential step in documenting patient care within North Carolina's Public Health Division. This guide provides clear instructions to help you complete this form efficiently and accurately.

Follow the steps to effectively complete the DHHS 4059 form.

1. Use the 'Get Form' button to obtain the DHHS 4059 Patient Visit Record and open it in your preferred digital editor.
2. Begin by providing the patient’s last name, first name, and middle initial in the designated fields. Ensure the information is accurate to avoid any discrepancies.
3. Enter the patient number which identifies the individual within the healthcare system. This is crucial for record-keeping.
4. Input the patient's date of birth in the format of month, day, and year. This information is vital for verifying the patient's identity.
5. Select the race category that best represents the patient from the provided list. If the patient identifies with a race not listed, choose 'Other' and specify if necessary.
6. Indicate whether the patient identifies as Hispanic or Latino by selecting 'Yes' or 'No.' This demographic information helps in monitoring health disparities.
7. Select the patient’s gender from the options available. If the patient prefers not to disclose, ensure to respect their choice.
8. Document the county of residence to assist in public health resource allocation.
9. In the vital signs grid, record the patient's height, weight, temperature, heart rate, blood pressure, respiratory rate, and other relevant measurements as required.
10. Capture the chief complaint by recording the patient's main reason for the visit under 'CC.' Ensure to be clear and concise.
11. Document any subjective data or medical history provided by the patient in the appropriate section, taking care to sign and date this entry.
12. Complete the review of systems by checking the boxes that apply to the patient’s current condition and documenting any exceptions or abnormalities as necessary.
13. Record the results of the physical examination in the provided space, including any necessary checks for accuracy.
14. Document any labs that were performed or ordered, along with their results, during the patient visit.
15. In the assessment section, note the diagnosis or findings based on the visit.
16. Outline the plan for treatment or next steps in the space designated for the plan.
17. Make any necessary referrals to other services or healthcare providers in the referrals section.
18. Provide education to the patient regarding their health condition and document it in the education section.
19. Ensure to sign and date the form in the signature field, noting credentials if necessary.
20. Finally, enter any follow-up notes or additional information relevant to the visit along with your signature to complete the document.

Complete your patient documentation online with ease and accuracy using this guide.