Home Forums Discussions General Discussion Past Encounters

OK, I have no idea why this question hasn't hit me for four years. I am wondering what others think about this.

I just now noticed that when you go to the past encounters section, the encounters are listed by Chief Complaint. Does anyone think these should be listed by diagnosis. I would think there would be definite advantages for doing so.

First, do we really want the subject line to read: Patient complains of red cheeks for two to three days; when the diagnosis is Erythema Infectiosum or Fifth's Disease? I suppose there are quite a few chief complaints that when read months later would not jog the memory of the provider. Plus, many times the chief complaints are misspelled, etc.

I must admit I rarely go to the summary sheet when looking at the chart or go to the problem list dropdown box (which really isn't a problem list). But, I do toggle between the Most Recent Encounter and Past Encounters. I think it may be more helpful to see a list there of:

Otitis media
Sinusitis
Otitis media
Fifth's disease
URI
Sinusitis

Just a lot easier to see how many ear infections they have had in the past year or so.

Just a thought. Any ideas?

Bert,
Great point! Those titles are created by us staff taking the appointment, right? They come from what we type in during the booking phase, yes? If not where does that title or line come from?

But none the less, yes the title probably would be much more professional if it comes from the providers final Dx of the patients problem verses what we at the phones first typed in or even what the nurse or MA first wrote as an initial complaint. In the end it is the provider who Dx's the issue and properly gives it a name. That first entery may be OK just for tracking it as the chart moves from box to box thru the visit, but in the end after the doc has charted the encounter, that title should change to something more offical Dx like.

I just showed this to Nancy and she said that if you doubleclick on the appointment in the schedule then it seems to come from the appointment note. If forwarded thru from Nurse/MA to the docs box, it comes from the Chief complaint that the assistant entered.

But either way, you are right on the money here.Very good. How did we all miss that? 1000 points to Bert.

Exactly! How did we miss that. That has to be close to numero uno on the things to fix. All of ours comes from our MAs, but even if I see a patient on my own, the chief complaint is supposed to be in the patient's words. So, if a patient says, "doc, been pukin' all day," that is the chief complaint in the patient's words. We are not supposed to edit that to Vomiting last 12 hours.

It's what's written in the chief complaint that populates the subject line of the visit history. Do we really want, "Every time I get up to go to the bathroom, I get dizzy," for the subject line. No, we want orthostatic hypotension there which would be the diagnosis. Maybe that should not be part of the note, but editable. I always have trouble with this. Say a patient has dysuria. You send them for a U/A and culture and the diagnosis is Dysuria. You don't know that it's a UTI yet. So, if we used the diagnosis as the subject line (which would be much better), then dysuria would be there. But, if the culture were positive, then I would argue for adding a slash like Dysuria/UTI.

That's the first thing I look at when trying to go back to review a patient's chart. If a five year old has three UTIs jump out at me, I know to make sure that at least an U/S has been done and maybe a VCUG.

Thanks Paul.

Bert,
But even if you charted the encounter before the results came back from a lab your best est'ed differential Dx would be lightyears better than dizzy when peeing with fever. And if the Dx evolves as data comes in that is perfectly cool. That is what really happens in this business. As the data comes in your understanding of the condition, issue evolves and changes, and so your notes, results, and title lines will show this proper adjustment to the changes in the data and your understanding of what you are dealing with. Perfect, just as it should be, right?

I gather that having the system insert your first top priority Dx listed would be the best thing to insert. That or allow you docs to actually insert one of your choosing, like your diff. Dx or final Dx with an edit capability. But who wants the PM's first encounter on the phone with the patient as the lead line and title of the note. Now obviously I try to be professional about it, but still, it is you guys, the providers who write the chart who need to be in control of this thing, not us second level staff members....

I couldn't agree with you more, although I imagine you enter a rather concise and accurate chief complaint.

Well, I think there would be pros and cons. About the only time I even look at the Past Encounters is to find out when a patient last had a complete (annual) exam. Those exams are noted by "Complete" which is entered as the Chief Complaint by the MA. Now, if I could remember to do so, I could in fact use "Annual Exam" or "General Exam" as my first diagnosis in the Assessment field. But then, that ICD-9 code shows up as the first code at the time of billing and, as many of us know, there are only a few insurance companies which will reimburse for a general, routine exam. (Instead, my diagnoses might be "Hypertension" or "Family History of Diabetes" or "Obesity"). Then my staff has to remember to remove this diagnosis code "General Exam" when filing the insurance or, worse yet, have the biller have to refile it with an acceptable diagnosis after it has been returned denied and unpaid. Honestly, I would rather get paid (still not a cent from Medicare yet) than have the most sensible helpful diagnosis show up in the Past Encounters section. Maybe the best thing to do would be to break the rules of history-taking and have the MA enter a simple phrase like "Thinks she has a uti" or "Rash" (just so you have some inkling of why the patient is there) and then have the practitioner edit that Chief Complaint to "Dysuria" or Herpes Zoster" before signing off. Pooh on always doing things the right way.

Leslie

Yeah I try, but sometimes I do just use the patients words because until Nancy has seen them, goodness knows what it really is. Nancy has a bunch of "when people say X,Y and Z I know exactly what they are talking about, they really have...." RLS is one of those kind of things. "You're going to think I'm nuts, but when I'm sitting on the couch at night...." Now with the recent ads on TV more folks who truely have it are coming forward. But I do put in what they report in the schedule line. Sometimes I might put in possible URI, UTI, Strep or what have you. But I feel it is NOT my place to change this self reporting, but to document what they told me. It is the clinical people, namely the doctor who takes the self reporting and her clinical observations and then she makes that diff. or difinitive Dx. That's certainly not my job, even if I do have an idea of what it might possibly be. That's practicing without a license. Just like the HMO's, right? Sorry I couldn't resist. Heck, even if you docs took the appointment yoursleves, it is still a Diff. Dx at best, right? Not until you have seen and probably laid hands on the patient should you be making a definite one, yes?

"It is inappropriate and dangerous to Dx and treat you over the phone. You need to come in." This is your call as the clinician, provider, doc, it is certainly not my place as the guy who answers the phones. Come on; your notes should obviously have a title that fits what you as the professional in the whole situation know or thinks that it is, not what the receptionist thinks it might be on first contact. This is almost silly. Soemtimes it is the most obvious things that we totally miss. This is one of those situations. No wonder you were the one that caught the URL, web address thing. You seem to have the "other" perspective for it.

You should certainly post this on the wish list to Jon and Vinny. Imagine someone reviewing your charts, even just another doc who needed notes or your patient moved, no less an audit of some sort (please no, keep the czar far away from us) "Puking with Dizzyness, Fever and Chills"... What a joke. This needs to be addressed.

Leslie,

Sorry, I couldn't disagree more. In our practice, when a patient comes in for a well child visit, the nurses writes WCC so that is what shows up in the messages.

I look at the Past Visits all the time (and this isn't about how some people do it and some people don't)When, you choose to show all progress notes and you see a running account of the notes, you will see the top of the progress not "Chief complaint: Runny nose and cough for three weeks" followed by Sinusitis as the diagnosis at the bottom. I think the past visit section should reflect the diagnosis. Rather than:

9/9/99 Cough
9/9/99 Runny nose and headache for two months
9/9/99 Rash
9/9/99 Cough
9/9/99 Cough
9/9/99 Fever for six days

It would be much better to have, skipping the dates for time sake:

Asthma
Sinusitis
Henoch-Schonlein Purpura
Croup
Croup
Kawasaki syndrome

This is the only place in the chart where one can pull up single progress notes bases on the name. These are the reasons they were here. These diagnoses. Some of these things don't make it into the Past Medical History. I need to know at a glance that this patient has two vasculitidies. Besides, once these resolve they are past medical history. I would hope if this patient was admitted and the resident asked their past medical history, the patient wouldn't list off six chief complaints but rather six diagnoses, which is what these are.

The summary sheet (which needs a major overhaul) lists the ICD-9s as a problem list, which it is not. A viral rash is not a problem it is a diganosis and, unless it lasts indefinitely, I wouldn't consider it a problem.

Just my humble opinion. I will sit back and wait for yours. <G>

Assuming that all of Amazingcharts is on Access database (a safe assumption, I suppose, as the medication database is on Access), I think the provider should be able to choose what they want in the description of the visit. I could even see that as a separate table where one can adopt cc: or Dx: as a default but allow us to tailor the description.

This will allow me to do more work inputting a new field, but will save me time in the long run... I can put what would be relavent for me in the future in the description box after the visit (CPE done, pap defer (menses)), or (WCC, Pediatrix not given (fever)), or (Pt abusive, fired from practice), or (third no show, DCd from practice), (lice, Rx Lindane), (multiple issues, see chart), (no more meds until labs), etc. It may or may not need to be part of the permanent record but would help in seeing what is being performed and what is not on a summary basis. This would also go well with the P4P type of guidance where there could be a spreadsheet where HbA1c, or urine microalbumin, when they are checked it's checked off in a box accompanying the description.

"Just a thought." -- Quote from storybook about the Little Pig who went to the Fox for Dinner.

I like your idea, Roy, but if we could even just toggle the view in "past encounters" from CC: to DX:, that would solve 99% of everybody's concerns.

Brian

Well, it wasn't even a concern until I brought it up (was it), lol. And Paul jumped in...yeah..

But, preferences are basically not allowed in AC last time I checked.

Bert - Tongue-in-cheek:

Why not pull it from the drug allergies and the RR, so...

9/9/99 Amoxicillin -- rash, 24

And, you wonder how I got over 500 posts.

Well, is there enough room to put both CC & DX? You could have two columns there and just display them side by side. You would get a very well-rounded idea of the visit from seeing both items, and everybody would be happy (ha!).

We should bump this thread to "Wish List" and Bert could send an email bringing it to Jon's attention (it was Bert's idea after all!)

Brian

I guess I will post after every post. I wouldn't worry about making everyone happy. I think it has to be diagnosis.

I will be a pointer post in wish list.

I am posting after Bert so he won't get the last word in, and I solemnly vow to keep posting after Bert, until I get tired of posting after Bert, or unless I get paged to the E.R., as I am on call.

OK, they're paging me.

Will Bert post again? We're all waiting in suspense!

Bert,
Not to pick your nose here but...Next time you get such an "been to the mountain and seen the light" kind of moment or insight; please start the thread on the wish list or problems.

Better yet, Vinny if you are listening is there a way for you as an big cheese to move things like this from one major heading to the other? This looks like a great place for such a thing. And Bert's right that we should try and keep all the banter back and forth on one single growing thread. Otherwise we'll lose track of where we are were, where we have come from, and where we are going. That can really mess up a good thread.

And Dx is the only thing that makes sense except for the messages that we save from phonecalls and the like. The note can have the chief complaint, that is what it is for. But the major title or heading of any one visit should be the doctor's call, and probably 90% of the time that should be the Dx.

Well, probably can't change it, but there is the pointer question. I am not sure if the wish list makes much of a change anyway. Still the same old posters.

By the way Paul, as far as the messgaes go, I have ideas on that also. I'll just throw a few out.

First, get rid of the Re, Re, Re...thing. Drives me nuts. And, my staff too; and they aren't OCD/Anal like I am.

Second, make three columns. From, Patient and message. So, in the Past Visit section, there will be the following:

Encounter: Asthma
Encounter: Bronchitis
Message: Wants Lamictal refill

We need (patient J. Smith)in the inbox so we know who the patient is, but we don't need it in the Past Visits. And, while we are at it, make it difficult if not impossible to send a message without a subject line. Outlook does it.

Gotta go. I have to call the ED to page Brian again.

And, ignore that green "bert" in the upper left hand corner, or the 516 posts or the Bangor, Maine. It's still not I.

Hey Bert, What's Brian's pager number?? This sounds like fun!!(Even though I hate the word "kudos", you get a bunch for all these recent gripes. When we have to email each other several times on a pt, that "re,re,re" stuff always makes me want to break out in Aretha Franklin's "Respect"!!

I think it's 55BRIAN, lol. That's good about the respect. Wait 'till you get the three patient (2 & 1) deal on the subject line.

Send me your email in my PM, and I will forward an email I sent to a few. It's pretty funny. Well, I think so anyway. But, then again, I didn't write this. Sshh! Don't tell Brian.

Bump

Hey guys,
As the Certified (yes that way too, lol) sports official here, I think that some of this would certainly qualify as "piling on". Sorry but I just couldn't resist the opportunity.