Medical Documentation Template

{
    "required_sections": {
        "patient_identification": {
            "description": "Complete patient identification and demographics",
            "required_elements": [
                "patient_name",
                "date_of_birth",
                "patient_id",
                "medical_record_number",
                "contact_information",
                "emergency_contact",
                "insurance_information",
                "primary_physician",
                "date_of_visit",
                "visit_type"
            ],
            "min_length": 150,
            "validation_rules": {
                "date_format_validation": true,
                "phone_number_format": true,
                "email_format": true,
                "required_fields_check": true
            }
        },
        "chief_complaint": {
            "description": "Primary reason for visit or consultation",
            "required_elements": [
                "main_complaint",
                "duration",
                "severity_scale",
                "associated_symptoms",
                "onset_description",
                "aggravating_factors",
                "relieving_factors",
                "previous_episodes",
                "impact_on_daily_activities"
            ],
            "min_length": 100,
            "validation_rules": {
                "severity_scale_1_10": true,
                "duration_format": true,
                "symptom_description_completeness": true
            }
        },
        "history_of_present_illness": {
            "description": "Detailed description of current medical condition",
            "required_elements": [
                "onset_date_time",
                "progression_timeline",
                "symptom_characteristics",
                "previous_treatments",
                "current_medications",
                "medication_dosages",
                "treatment_response",
                "side_effects",
                "compliance_status",
                "recent_changes",
                "associated_symptoms",
                "functional_impact"
            ],
            "min_length": 300,
            "validation_rules": {
                "chronological_order": true,
                "medication_dosage_format": true,
                "treatment_response_documentation": true
            }
        },
        "past_medical_history": {
            "description": "Relevant past medical conditions and treatments",
            "required_elements": [
                "chronic_conditions",
                "acute_conditions",
                "surgeries",
                "hospitalizations",
                "allergies",
                "adverse_reactions",
                "medications",
                "immunizations",
                "family_history",
                "social_history",
                "occupational_history",
                "travel_history"
            ],
            "min_length": 200,
            "validation_rules": {
                "allergy_severity_documentation": true,
                "surgery_dates_and_complications": true,
                "family_history_relevance": true
            }
        },
        "physical_examination": {
            "description": "Comprehensive physical examination findings",
            "required_elements": [
                "vital_signs",
                "general_appearance",
                "constitutional_signs",
                "head_eyes_ears_nose_throat",
                "cardiovascular",
                "respiratory",
                "gastrointestinal",
                "genitourinary",
                "musculoskeletal",
                "neurological",
                "skin",
                "psychiatric",
                "abnormal_findings",
                "assessment_notes",
                "examination_date_time"
            ],
            "min_length": 400,
            "validation_rules": {
                "vital_signs_completeness": true,
                "systematic_examination_order": true,
                "abnormal_findings_documentation": true,
                "normal_findings_documentation": true
            }
        },
        "assessment_and_plan": {
            "description": "Clinical assessment and treatment plan",
            "required_elements": [
                "primary_diagnosis",
                "secondary_diagnoses",
                "differential_diagnosis",
                "diagnostic_codes",
                "treatment_plan",
                "medications_prescribed",
                "dosages_and_frequency",
                "duration_of_treatment",
                "follow_up_plan",
                "patient_education",
                "lifestyle_modifications",
                "referrals",
                "prognosis",
                "risk_factors",
                "monitoring_plan"
            ],
            "min_length": 350,
            "validation_rules": {
                "diagnosis_code_accuracy": true,
                "treatment_plan_specificity": true,
                "follow_up_timeline": true,
                "patient_education_completeness": true
            }
        }
    },
    "formatting_requirements": {
        "standard_medical_format": true,
        "clear_chronology": true,
        "proper_medical_terminology": true,
        "legible_documentation": true,
        "date_time_stamps": true,
        "consistent_abbreviations": true,
        "proper_units_of_measurement": true,
        "standardized_terminology": true,
        "clear_section_headers": true,
        "proper_paragraph_structure": true
    },
    "quality_standards": {
        "clinical_accuracy": true,
        "completeness": true,
        "clarity": true,
        "legal_compliance": true,
        "privacy_protection": true,
        "medical_terminology_accuracy": true,
        "dosage_calculation_accuracy": true,
        "diagnosis_supporting_evidence": true,
        "treatment_plan_appropriateness": true,
        "follow_up_adequacy": true,
        "risk_assessment_completeness": true,
        "patient_safety_considerations": true
    },
    "compliance_requirements": {
        "hipaa_compliance": true,
        "medical_standards": true,
        "documentation_standards": true,
        "privacy_protection": true,
        "jcaho_standards": true,
        "cms_documentation_requirements": true,
        "state_medical_board_standards": true,
        "professional_liability_standards": true,
        "audit_trail_completeness": true,
        "informed_consent_documentation": true
    },
    "detailed_checking_criteria": {
        "vital_signs_validation": {
            "blood_pressure_format": "systolic\/diastolic mmHg",
            "temperature_units": "Fahrenheit or Celsius",
            "pulse_rate_range": "60-100 bpm normal range",
            "respiratory_rate_range": "12-20 breaths\/min normal",
            "oxygen_saturation_range": "95-100% normal range"
        },
        "medication_validation": {
            "generic_name_required": true,
            "dosage_format_validation": true,
            "frequency_standardization": true,
            "route_of_administration": true,
            "contraindications_check": true,
            "drug_interactions_check": true
        },
        "diagnosis_validation": {
            "icd10_code_accuracy": true,
            "diagnosis_supporting_evidence": true,
            "differential_diagnosis_completeness": true,
            "severity_assessment": true,
            "prognosis_documentation": true
        },
        "documentation_quality": {
            "objective_findings": true,
            "subjective_complaints": true,
            "assessment_clarity": true,
            "plan_specificity": true,
            "follow_up_instructions": true,
            "patient_education_provided": true
        }
    }
}