Home Forums Discussions General Discussion Old guy/New program

As you can see by the subject, I am new to ANY EHR after many years of practice. The tutorials seem to show a totally different flow to medical documentation than I have used. In the example, someone with a URI has a brief HPI, but then the templates for the ROS are used to say things like "no fever, shortness of breath, etc." My training was that this always went in the HPI, and if the HPI were complete, there was little left for the ROS except for unrelated problems. The PMH was for closed issues, like old unrelated surgeries.

Similarly, the assessment window is what I am used to thinking of as the problem list, but is being used as the place to document the treatment plan. The Plan window seems to be sort of disconnected stuff.

I agree that AC is very intuitive and easy as long as I free-text or build templates that do everything "the old way" , but I am worried that the entire flow of medical documentation may have changed while I was not looking and may need to be re-learned for the modern world. Is there a new expected form of the medical record?

You can develop whatever templates you want. I use the assessment as the current problem list as well as the diagnoses I am using for that chart note - I actually use the PMHX - I put 2 categories - 1 for Past Medical History - a, b,c and then in the same box I Put Past Surgical History - Appy, Chole, etc.

The plan is where all your orders, what you do, etc is listed. Once you do a few charts on sample patients you will get the hang of it.

Hi Dgrauman, I use the EMR the same way you do. The only limits I have encountered taking my style of charting to Amazing charts are:
1- the box for Chief Complaint is small and doesn't allow my MA to write much, with me adding my two cents worth.
2- The Assessment, which is indeed the problem list, does not accommodate any sort of number system to allow my plan to be tied, item by item to the problem list. That would be nice, but really important if it would carry onto the super bill, allowing the "Chest Pain" and "EKG" to match up.
But otherwise it is just like my old notes.
One change I made was where I used to add a separate block of text to highlight a procedure, I now have those as templates under the Assessment. So while I usually treat the Assessment as only the problem list, when the problem is "Actinic Keratosis" Then the Procedure note is appended to the Assessment to help me see that I did the procedure and to make the procedure templates easy to find. (they are the only templates I have under "assessment".
It works pretty darn well.

Everyone does things a little differently.

Jon put the developmental info for toddlers in ROS, I use SH, no big deal. Once you have developed enough templates (and at one a day that would be over 200 in a year) his templates are not that necessary.

I'm not sure I use any of his (perhaps no signficant PMH, not sure if he made that or me) on a regular basis. I'm not sure why I don't delete some of his, I haven't, I just ignore them.

Jon, if you read this, I still think it is a great program, I just like my templates better.

Hello old Alaska guy,
The answer to your question "Is there a new expected form of the medical record?" is "yes".

I learned to create a note in much the same format as you. If you want to know why we are being pushed to change, take a look at how we get paid for office visits. In the past, my ROS was pretty empty, like yours. Now if you document multiple negatives, you get paid more. A family and social history in EVERY note...what a waste of time and paper. But the reimbursement gods have deemed that we get paid more if that is put into each note. So though it seems to minimally benefit the patient to repeatedly document these things in the note (of course you MUST ask the questions) you get paid more to do so. So the "default" in EMR's is to prominently include a place for a multisystem ROS, an FH, and an SH.

I grappled with the same issues when I first started using AC. My preference would be an EMR that allows us to customize the categories to our own habit, but I agree with Martin and Steven that once you adapt a little, you will be comfortable with the program.

The way I do it (which I think is pretty similar to your "old" approach) is as follows. One thing you will note is that the order is different-this you cannot change:
HPI- just what you are accustomed to. Includes the portion of the ROS for the one organ system appropriate to the chief complaint.
ROS- a long list of negatives
PMH- as you said, basically the PAST history, which doesn't change much. I divide it into PMH and PSH as Steven describes.
Allergies then meds (I know; seems backwards)
The problem list is automatically populated by the diagnoses you insert in the assessment area. You must select the ICD-9 to make that happen. If you like a complete problem list, this is kind of handy.
Assessment- If you want to keep adding diagnoses (making a problem list) you can, but I use this as the assessment for the one particular visit I am writing the note for. I can have a separate problem list but here can quickly see that day's impression.
Plan- is not really a jumble; it is what you want to do that is new,including prescribing and orders.

I suppose it is good for us to be flexible as we get older...???

Wonderful answers from all. (insert sound of someone taking a deep breath. )

here we go......

dgrauman,
While you're at it, you might check out Dr. Peter Jensen's webside www.emuniversity.com for some insight on efficiently documenting your visit and getting paid appropriately for it. I have no association with the website, but am a frequent flyer there. The concept that after XX years of practice you KNOW what level of complexity the visit is, then working backwards to make sure you document the elements of the history and physical to support that level was an epiphany for me. Also, I've learned the documentation does NOT have to be verbose. Look at his examples of 99214 and 99215 cases and you'll be shocked at how little verbage can be used and still fully qualify as appropriate documentation. You can purchase his tutorials, but frankly, I've always found the free stuff to be sufficient. Dr. Jensen is a nephrologist and certified professional coder. Again, I'm just a fan and am passing along a tip that I use in my practioe daily. If you are going to be making new templates, EMUniversity is a great place to start.
Dave