Happy 10th anniversary. I wonder with the many huge EMR programs like eClinicalWorks or eMDs or NextGen, if they have a board and many post. I don't think AC always realizes (given some of the issues over positive and negative feedback) how the consistent posters to the board have helped shape AC. And, while the shape may be different than what we want, we do move toward a better shape because of Chris C. For better or worse, Chris has been the one that came in and began to really develop the program forward.
Anyway, I spent 10 minutes reading that link. Wow, were we nice to each other then. Hell, I was even nice. I guess I forgot but I do see how the SOAP note can be done now thanks to Travis. When AC wasn't as developed, workarounds were much more prevalent.
Bringing up the workaround stated, I wish there were a way to leave out things as well. Maybe someone can enlighten me. I haven't tried hard, but I still have ROs, PMH, unused VSS fields, and Goals, Health Concerns and Instructions listed even if I don't use them. The respiratory rate, pmh, instructions, etc. stick out like a sore thumb if you don't use them. Seems like if a field isn't used, it shouldn't be labeled.
While we are at it, it did make sense to have someone or the doctor add, "updated by so and so on such and such a date." But, then it stays there forever.
While we are on it, I still try very hard to leave the chief complaint empty and write it in the HPI, and after the assessment, I typed the diagnoses in caps in the CC field. Once again, fever and fatigue or just fever and irritability means nothing in the past encounters, while LYME DISEASE and RIGHT OTITIS MEDIA are much more helpful.
I suppose on Leslie's point having the PMH and FH addressed by the specialist does show they looked at that, but as Jon says, we don't need that on every note.
The note is way too cluttered, and the old-fashioned dictated SOAP note, while likely not as helpful for CPT, E & M and thoroughness due to forced fields, is so clean and so helpful. ED notes were great that way.
I don't find that the AC's EMR slows me down, but I can see how an ED doctors would think the notes they use do. Now we get these APSO novels from H & Ps, discharge summaries, consult notes, ED notes. Most PCPs hate them.
I love the consultant that writes, I know you know the history but please allow me to document it for my record. Then, they write a
history which is five times better than mine.
We have a neurologist here, whose basic note is:
S: Patient returns for f/u seizures. Keppra working fairly well. Has had two seizures since last month.
O: Still looks like the same patient from last month. No fevers, weight and height ____________
A: Better. Seizures still on monotherapy.
P: Will add second anti-seizure med and get EEG in two weeks.
Thank you for allowing me to participate in this young man's care. (Jon are you guys really happy to participate)
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There was a time, not sure if they are still doing it, that the ED docs were forced to write this differential diagnosis. A kid would come in for fever and listlessness (our work for the parent's lethargy). They would list I considered viral syndrome, sinus infection, meningitis....
Well, it was good to list them, but I always felt that stating you considered meningitis, but you did nothing to rule it out: CBC, spinal tap, etc., was a lawsuit in the making.
