Electronic Health Record Checklist Form
Complete this checklist to ensure all key steps in the electronic health record workflow are addressed. Do not enter sensitive personal or financial information.
Date of Encounter
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department
*
Please Select
General Medicine
Pediatrics
Surgery
Emergency
Obstetrics & Gynecology
Orthopedics
Other
Provider Name
*
Type of Encounter
*
Initial Visit
Follow-up
Consultation
Telemedicine
Medication Review Completed
*
Yes
No
Not Applicable
Allergy Status Verified
*
Yes
No
Not Applicable
Consent Documentation Confirmed
*
Yes
No
Not Required
Clinical Notes Entered
*
Yes
No
Orders Placed (Labs/Imaging/Referrals)
*
Laboratory Tests
Imaging
Referrals
No Orders
Additional Comments
Submit Checklist
Should be Empty: