OK, the biggie. And, I will need input on this.
Chief complaints, PMH, Problem list and diagnoses are different things.
1. Past medical history are just that. Things the patient had that aren't active but could affect the patient. Things like Appendectomy 2004 is past medical history (or surgical). It is not a problem, active or inactive. The past medical history must be typed in and is in the right place.
2. Chief complaints: CC are typed in under chief complaints. A chief complaint is defined by what the patient states in their own words. Herein lies the problem. The patient will say Fever or Pain in left shoulder or I get dizzy when I walk to the bathroom. Or Ear pain.
The issue is what is written in the CC is what populates the Past Visit History. So when you look in the past visit history or Past Encounters, you will see:
Fever
Pain in left shoulder
I get dizzy when I walk to the bathroom
Ear pain
This is NOT helpful at all. One will come up with a diagnosis at the end of the "Encounter" and that is what should be listed in the "Past Encounters" So it should say:
Viral infection
Bursitis
Orthostatic hypotension
Acute otitis media
When a parent asks how many ear infections their child has, I can't tell by seeing a list of Acute otitis media mixed in with Ear pain or Fever, etc. I need to know there were five ear infections in the past two years.
So, this would be populated from your diagnosis. Your ICD-9 code. The problem I have always forgotten is what if there are three diagnoses. I forget that FP docs see patients with more than one issue many times. How do you get all three to show up? Is there a primary diagnosis. Or do you just list all three?
Finally, there is the problem list. These are not PMH. These are not past encounters. They are either active or inactive problems. Currently, the problems are populated, ironically, from the diagnoses and show up in the Summary Page. I have NEVER looked there. It helps with the printout of the chart. Problems should show up somewhere on the encounter, so you can either see them or click on them and have them populate the Assessment. Or you can inactivate them. I don't know how many times that I have re-diagnosed a VSD on a nine-month-old. Sure, it can be in PMH. But, sometimes it scrolls off. And, I don't generally look there.
Thoughts?
