This section includes the following information:

Diagnosis, Problems & Conditions are preferably ranked by order of importance or in reverse chronological order. They are described in plain English and by code, according to the selected cording sys4tem. Also included are date of onset, date of most recent resolution, status, patient awareness of conditions, family history, social history, and a source field.

Adverse Reactions/Alerts lists allergies by agent and symptoms with optional fields for source and date of last reaction, as well as other pertinent alerts about the patient.

Current Medications are listed by brand name, generic name (optional), code system, code start date, dose schedule, refills, prescribed, status and a comments field.

Immunizations Documentation includes information about each disease against which immunization was given, the date the immunization was received, and (optional) dose strength, unit and route of administration as well as manufacturer and lot #.

Vital Signs documentation’s includes height, weight, blood pressure, temperature, respiratory rate, date vital signs were recorded, pulse oximetry, and optional peak expiratory flow rate (PEFR), as well as head circumference (for Pediatrics).

Laboratory Results documentation includes blood sugar, urine protein, creatinine, sodium, potassium, hemoglobin, hematocrit, WBC, and the date the sample was taken.

Procedures/Assessments documentation includes descriptions of procedures, code system, procedure code, procedure date time, location, result and performed by whom.  Also included here are assessments, such as mental health assessment, functional assessment.

The Health Status section may be amplified in the optional “extension” for medical specialty-specific information. For instance, pediatric providers may want to include a growth chart in the CCR.