Hi John,
Thanks for your detailed response. It is very helpful and, as you say, points out the different work flows. It seems as though you rely almost solely on the PMH window. It is ironic that the PMH that is no longer relevant, you term Inactive Problems, just as I would think of the top half as Active Problems.
From your description, it would seem as though it would be helpful if that box were much larger. It would be easy to lose track of your notes or consultants without scrolling. Or do you use Enlarge Textbox? For your purposes, if I were AC and wanted to revamp the notes field and I wanted to enable your flow, I would likely make some changes to the PMH. I guess you could even refer to it as Past Medical History and Problems.
I am also wondering, given you document your diagnoses/problems in the assessment field and then talk about what you did in the plan. This seems very logical. But, do you retype in the problem you are addressing? Would it be good for the diagnoses or problem you document automatically populate the plan section? Or give you a check box to choose a preference. Maybe if there were a check box next to every diagnosis, you could check them if you want them to go the plan.
I have to say that your way of doing the CC wouldn't help me at all. I would argue that f/u BP is more helpful if that were the chief complaint, but the encounter field stated Hypertension or Hypertension, resolved. And, once again, that CC by the patient of "I think I have URI," not only looks terrible in the encounters, but could turn out to be Allergies.
Finally, I have questioned this several times, and it happened to me again today. Let's just start with a new patient so it is easy. I see them and diagnose them with Acute Bronchitis. Next time with Atopic Dermatitis. Now, if I need to get a CXR for Difficulty Breathing, and I select a diagnosis of Respiratory problems, the diagnosis is there for the CXR, but then goes away. But, should that be a diagnosis which stays? Or should it at least stay for future labs/radiographs?
