Clinical documentation is an important extension of a genetic counseling encounter. The traditional types of clinical documentation include the clinical visit note (including follow-up visit note), letter to the referring physician, letter to the patient, and result summary to the patient and referring physician. Increasing patient volumes, new genetic counseling service delivery models, transition to electronic medical records (EMR), new specialty clinics in genetics, and advances in genetic testing technologies challenge the practice of writing multiple types of clinical documents. This practice resource (PR) seeks to provide best practices for U.S.-based genetic counselors to write efficient and comprehensive clinical documentation using a hybrid clinical document designed to facilitate communication between individual providers, providers, and patients/families, and providers and payers. The content of the hybrid clinical documentation will vary by genetic specialty but may include a summary of genetic services evaluation, genetic testing options and eligibility information, genetic test results, potential risks for genetic conditions, implications for family members, and medical management recommendations. An outline of a general hybrid document along with examples of hybrid clinic notes for three types of genetic counseling specialties is included in this document.

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遗传咨询临床文件：国家遗传咨询师协会的实践资源

临床文件是遗传咨询会议的重要延伸。传统类型的临床文件包括临床访问记录（包括随访记录）、给转诊医生的信、给患者的信以及给患者和转诊医生的结果摘要。不断增加的患者数量、新的遗传咨询服务交付模式、向电子病历 (EMR) 的过渡、新的遗传学专科诊所以及基因检测技术的进步，对编写多种类型的临床文件的做法提出了挑战。该实践资源 (PR) 旨在为美国遗传咨询师提供最佳实践，以使用旨在促进个体提供者、提供者、和患者/家庭，以及提供者和付款人。混合临床文件的内容因遗传专业而异，但可能包括遗传服务评估摘要、基因检测选项和资格信息、基因检测结果、遗传病的潜在风险、对家庭成员的影响和医疗管理建议。本文件包括一般混合文件的大纲以及三种遗传咨询专业的混合临床笔记示例。对家庭成员的影响和医疗管理建议。本文件包括一般混合文件的大纲以及三种遗传咨询专业的混合临床笔记示例。对家庭成员的影响和医疗管理建议。本文件包括一般混合文件的大纲以及三种遗传咨询专业的混合临床笔记示例。