Hi Marty and Indy,
I reviewed your discussion and I think that I understand your problem.
Our practice is to print out the Summary page of AC and keep it current (replace as necessary). Each visit the patient is presented with the current Summary page at the receptionist desk and confirms that his/her demographics, diagnoses, medications etc. are all correct. They make the appropriate corrections on the sheet with a pen and I then change them during the visit on AC.
I would suggest to Marty that a commitment be made to complete each chart in the room (a recommendation made to me by Bert and I am very appreciative that I followed his advice). I still do not sign off on the charts in the room (I forward them to myself after I complete them in the room and than sign off at my leisure; this allows me the ability to retrieve the still active chart when a patient decides to add a comment, a question or a prescription request as we complete the visit.
I am able to complete the charts in the room because I make use of templates (except fot he HPI which, in my opinion, should almost always be individualized).
I also suggest to you that you add an additional template for your Plan portion of AC: "The patient has read and signed off on the electronic record as transcribed above - the dated signature is in the hard copy chart". This entry will then require only a right click on your mouse and a single click for each patient.
You then place a copy of a single piece of permanent lined paper in your hard copy chart that has a heading "Signatures on this page confirm that this patient has read and understands the entry including history, assessment and medications on the date signed". That single piece of paper should be sufficient to cover twenty or more visits.
Your thoughts?
Best,
Jim
