To clarify, Brian:
I am not auditing their ENTIRE chart. No, I am entering the data from the LEFT side of our paper charts, i.e. med list and problem list and health maintenance flowsheet (paps, mammos, BMD, colo's, DRE's, cholesterols), narcotic flowsheets, diabetes flowsheets.
This is why I review with the patient as I go, because they undoubtedly remind me of a recent colonoscopy or a recent elevated cholesterol-->something recent that may not have made it onto my chronic problem list.
Like I said, there are some patients where time does not permit entering EVERYTHING in the room, but I am doing my best to try.
The first 4 weeks were HELLISH, and I didn't get home before 11pm.
However, the last 2 weeks have been 100% easier. You see, 75-80% of our thickest charts have been entered. So, I'm working on a lot of thinner charts and healthier people. The recent influenza mini-epidemic in Maine has been wonderful from a certain perspective--> many previously healthy patients are coming in to be evaluated. This allows me to do data entry that might not have been done for a long time.
