(This might be a bit of a Rant, so feel free to skip, sorry, but now I feel better!)
I also felt the best work around was to have 'an encounter' just for data entry. It worked very well, (until meaningful use). I liked it so much I expanded the concept for orders that are the result of labs, or to document phone calls. It works like this:
I open the chart and hit "Control N" to get a fresh encounter page. In Chief complaint I open the templates and select:
-The patient was admitted to the hospital on this date:
or
-This entry will record the following call.
or
-This entry is for consolidation of the medical record:
or
-As we leave the room, the patient relates:
or
-As a consequence of labs reported the follow action is taken:
or
-The Mammogram requires additional views.
I believe each of these is self explanatory. It began as a means for me to add family/social/Past Medical or Surgical history to the chart and have a means of recording the data with the least trouble or extra work.
When I admit a patient to the hospital, a simple note: Hospital Admit with HPI just, "GI Bleed" allows me to SET THE DIAGNOSIS CODES IN ORDER so that every subsequent day, when I use an addendum to record "Patient seen by Sechrist" the superbill will have the pertinent ICD-9's in the right order!
Likewise if I record an encounter for "a consequence of Labs" and the HPI is routine labs with UTI, I have a record dated and timed of when I set treatment in motion. I enter the diagnosis code, send an order, (now documented) that says, "Susie please call Mrs. Jones to let her know her labs came in, and there is a UTI that should be treated, she can get her Rx at the Pharmacy, I already sent it". And of course the transmission of the Rx, all is documented.
LIFE IS WONDERFUL.
And so of course everyone of these encounters is without vitals, because they are a sort of virtual or cerebral encounter, not a 'meaningful' one.
Now on the subject of vitals I am really serious. EVERYONE EVERY TIME, even the tearful member of weight watchers who refused to be weighted gets walked back to the scales by me personally so we don't get sloppy.
SO IMAGINE MY SURPRISE when I printed our "meaningful" report and found I was only hitting 91% on vitals!!!
(Of course what I take this to mean is that I am doing to much for free, and should make every one of these patients come in, (get vitaled) and sit down for a chat while we treat that UTI or order those extra views on that Mammogram.)
