Home Forums Discussions General Discussion Past surgical history

Just migrating to AC from paper and seeking help on placement of past surgical history. This seems to be fairly important pieces of information and it seems to easily get lost in AC as the summary sheet has no place for PMH/PSH or even allow for entry of procedure codes and unless one uses a previous visit as a template, one has to dig thru previous visits to pull out the PMH/PSH. I have imported a speadsheet into the Imported Items section but that cannot be viewed or edited within AC. So I'm left scratching my head.

Guidance for my fumbling ways would be greatly appreciated. Thanks ahead of time!

I use PAST MEDICAL HISTORY -

I put in Past Medical History and Past Surgical History and type them in.

Terry, I had a lot of the same problem. The entire chart organization in AC was just very different than I had been used to, coming from a SOAP problem oriented medical record background. I felt like a moron.

Personally, I use the Past Medical History for things that are over and done with: a section for surgical, a section for medical ("pneumonia, 1983") and maybe a section for things like last colonoscopy and vaccination status (until we decide to try out the health maintenance section). My partner, on the other hand, uses it as a place to list active problems that need to be addressed pretty much at each visit. I just leave those in the problem list.

The review of systems makes me a bit nuts. Unless I am doing a comprehensive examination, I always feel that pertinent negatives go in the HPI, and the ROS should be blank. Reimbursement rules dictate something go in there, so I put something in there, but it never seems germane or useful. Might as well template a recipe for goulash and put it in.

Reading lots of posts here, it is evident that one of the good things about AC is that you can adapt it to whatever style you want. Each "field" is really just that; a place to put in whatever you want. Some folks started in early versions of AC just dictating everything into a single field, for example. I ended up somewhat changing my "style" but not entirely. But then again, I am old and crotchety enough that I really don't care if anyone else likes my notes and have no illusions about being paid better if I do it their way.

I too am used to a SOAP orientation and am used to seeing the sheet on the left side of my chart that displays the PSH in a glance. It is also shift to break out the problem list as something separate from the PMH and PSH.

It appears that each subsequent visit populates the PMH field from the previous visit. So I suppose as long as we make sure we pull that field through with each subsequent visit, we'll be ok. I am just concerned that data will be lost if not pulled through with each visit.

I hope I'm making my concern clear.
Thanks for the responses.

Yes, as long as you keep it up to date, and start each encounter by choosing File ->New note -> New note (save PFSH) then the new encounter record will start with all the previous data intact.

I hadn't picked up on the New note (save PFSH) command. That would solve my concern as long as it pulls that data from any the latest visits with those fields filled in.
Thanks!

Which is why it would be so nice to be able to rename those fields.

Does the New note (save PFSH) command pull those fields from the last visit or the last time those fields were used?
If the last visit did not populate the PFSH fields, then does the next New note (save PFSH) command pull from those empty fields?

It pulls from the last visit. However, if you mess up and left those fields empty the last visit, you can choose an earlier visit to start with from the pulldown list at the top, over the chief complaint. Then do New note (save PFSH) and the note will revert.

Actually, my partner is considering doing just that when we get to the second comprehensive exam for a patient in AC next year. I'm not certain I totally get her thinking, but I believe that the way she uses the past Hx it may allow her to revert to the old "original" version and bring it up to date without filling it with interim problems.

And yes, Jon, it would be nice to be able to rename the fields.

Thanks for the clarification. A workflow is slowly forming in my foggy brain...

Terry, since we're both Internal Medicine, I'll throw in things I found when I started.

I really had some trouble at first adapting and getting my note to show useful information. I found it useful to print out a few, and look at it the way an outside party would look at it. Then I modified what sorts of things I put where.

I also got rid of most of the templates that came with AC. Some folks seem able to use templates extensively even in an Internal Medicine practice, but they just did not seem to fit what I was doing as an internist. I did make up some templated physical examinations, and that is useful, and some introductory information discussed in the "template %" and "Placeholders in templates" threads gets used in the HPI. The rest gets dictated in using Dragon Naturally Speaking.

I will say that on those occasions when I see someone with a headcold or backache the templates are wonderful, but that is not what I see in my practice.

I get way too many records from other practices that have several pages of templated information that you KNOW were never addressed. My favorite is a practice that insists it asks if the patient has been incarcerated on every visit. I really, really don't want my records to look like a robot did them.

As I looked at EHR's and finally chose this one, it had become clear that the diversity of issues I address with most visits would not be adequately addressed by templates, except for the URI's, back pains, etc which is a minority of visits.

It is good to hear that Dragon works as I have that on order. Is it worth the money to get the Medical version? It seems ridiculously priced.

My favorite consult notes here are the ortho's and ENT's who include neurologic and psychiatric ROS's to justify their ridiculous charges for cerumen impactions and sprained ankles...

Thanks greatly for your input.

There are several threads here about Dragon V. 10. (See "voice dictation" I bumped back towards the top) Bottom line: You need the medical version to work with AC or any EHR, no choice (program will shut down with others.) Version 10 medical is very good. It is ridiculously priced. Getting it through a medical software dealer is a plus, as some setup adjustment was very helpful for us, and having someone to respond to a panic call when you are down is reassuring.

Pretty sneaky to shut AC down because you didn't buy the expensive version...

I'm unclear if it a company choice, or mandated by certification requirements. The result is the same, however. Anyway, it's a lot cheaper than the $1500 a month our 4 provider group used to pay for a lousy dictation service.

David, it was most definitely a choice made by Nuance (Dragon's owner). It was a choice which led many users to vow never to purchase their product again. I don't think AC nor any of the other EMR company's were too happy about it either.