Home Forums Discussions Problems How to Create Working Document in AC

Hi All.

I am new to AC and trying to figure out how to implement it for our holistic & integrative practice. The Dr. here sees patients for 1 hour at a time and discusses several different health issues in one visit.

I'm trying to figure out if there's a way to create some sort of "Working Document" that keeps a summary of all relevant information on a particular condition being evaluated (ex. Lower GI problems).

I thought at first to put everything in the HPI section of the encounter. However, there is some information that we would need to add to this "repository" when the patient is not in the office (ex. most recent comprehensive digestive analysis results - so that it is all summarized there for the doctor and she doesn't have to look around for the necessary information). We wouldn't want to create a new encounter if the patient is not actually being seen just to enter this new information.

Any ideas on how else we might be able to achieve this effect in AC? Messages cannot be edited after they are made, right? And I am not sure addendums would work either.

It may be that this just isn't possible, which would be helpful to know as well so that we can start brainstorming something else.

Thanks for your thoughts.

Cheers,

S.K.

The easiest way to work around that in my opinion is to do just what you said. Make a new visit, BUT no bill and the Chief Complaint should help you skip the visit when you are scanning the prior visits.
I use the following templated statements:
"As a Consequence of Labs"
"This entry will record the following telephone call"
"As we leave the room the patient relates:"
"This entry is for the consolidation of medical records"

I guess these are self explanatory, but the point is, these are all used to cover the time that an entry needs to be a part of the permanent record, but no bill (or no second bill) will be generated. Also when you look at "Prior Encounters" you don't need to pour over the note to figure out that it is just an addition to a note that was already signed, or it is the orders to respond to abnormal labs.

I would use the past medical history section for a working document. This comes up with each new encounter and can be edited. If you are just updating the history, then put a note to that effect in the chief complaint section like DocMartin said. You can also use the HPI section just bring forward the last visit at each encounter or update.

S.K.

Everyone talks about putting in an Excel spread sheet for each patient in Imported Items and bringing it up for labs, problems, etc.

No one talks about Word or Wordpad (which would open more quickly).

You could make one Word document and set it up as you want and set up auto time and date for each entry.

Then, you could import that document to Imported Items as each patient is entered into AC or after if you wish -- always keeping the original. Your receptionist would do this. At each visit, you could pull up the document from Imported Items and write things in. That would be an easy thing to do. People will always say you can change things so it wouldn't be HIPAA compliant.

Just write at the bottom:

This document is to be used solely for information for the doctor and practice and is not meant to be part of the official chart.

For me, who cares. Sorry. If it helps, I wouldn't care about HIPAA. Last I checked the HIPAA police ran out of funds. I have never seen them. I jest a little, lol, but just an idea. And, if you talk with a Microsoft Word guru, they may be able to tell you a way that after you save it for that visit, it can't be chanced until the next entry.

Agree with Word documents, the only thing I have stuck with the Accell sheet is for the Coumadin dosing, it calculates the daily average and makes the changes easier.

Martin,

It's funny about the Microsoft Office Suites. Each one allows you to do millions of things, but I only end up learning and using about 1%. Excel can be a very powerful app. But, I can barely use it as a spreadsheet.

Accell ignition parts, Excel the spread sheet thing, whatever. (oops)

Hi All,

Thank you for your great suggestions. So, you can make changes to the HPI or PMH sections without needing to "sign the chart" and generate a new superbill? Or you would jot the notes, sign the chart and just cancel the superbill (not put any CPT codes) and then the note would show up in the "Past Encounters" section as an Encounter with whatever you type in the "Chief Complaint" section as the Subject?

The Microsoft Word document is also a very good suggestion...

Thanks so much!

S.K.

I can only speak to v4, but I do not know of a way to add to PMH or HPI without bringing up a new chart.

You can correct sections and not save the superbill. If I need to correct a note, I write under CC: changed xxx or added Rx or such then correct the note. Upon signing it a box will pop up stating there is a superbill for that day do I want to add another, say no and you are off to the races. Both visits will show.
It is the same in V4 as V5