Home Forums Discussions Problems Seeking suggestions for charting

I am still a neophyte user of AC. To date, I have used AC to set up new patient charts and to enter existing patients when they come for PE. So, those notes are complete with all sections. Now, I am beginning to use AC for followup visits and sick visits with the patients who have been entered. When I use a prior visit to start the note, I am trying to decide whether to carry forward all of the PMH, FH, SH, etc into each subsequent note. It seems like it makes the notes exceedingly verbose if I do include it all. (In my paper chart, I had a summary sheet on the left page always visible, and I would just chart a SOAP note on the right progress note page, no need to re-document all the unchanged info every time) Could I have suggestions from experienced users, please?

Donna, here is my take on it.

Leaving aside documentation/reimbursement issues,the PH, FH, SH, etc. are isolated snippets of data that live all by themselves in their own little cubbies of the patient's chart. Whether you choose to show them or not is kind of immaterial... they are not really duplicated with each note, just displayed or not.

If you do not wish to see those pieces of data when you review previous encounters, you can just click the button for assessment and plan only, and skip to the chase of each note.

I choose to show them for each new note because every once in a while... not all that often, but sometimes... there is something there of which I need to be reminded. (Oh, yeah, his daughter was killed in a car crash last Fall, about the time he now says the stomach pains started....") I figure it is harmless to show the data, and sometimes helpful. If someone else has to wade through all that stuff when I transfer care, that is their problem.

I agree with David. I like seeing all the old stuff on the left side and I refer to it often. I also use the areas such as the Social History to make comments on things I can bring up to the patient which they love, like they have a Whippet named Pierre. I agree, I really do not care if someone else has to wade through that extraneous stuff. I still maintain the EMR, just as any medical record, should be for the benefit of the doctor and the patient.

Pierre? Really?? Now, "Thor", or "Squalus" I could understand, but "Pierre???" ;-)

Thank you for these suggestions. I will do as you say, and carry it forward. Then, each note serves as its own "summary sheet". I am trying to learn how I must adapt to the EMR. After 20 years of charting in an efficient (albeit less legible)paper fashion, this old dog must must learn some new tricks.

As an aside, one of our colleagues, Ray Wilson (rheumatologist), has recently moved to Alaska. David, I wonder whether you have crossed paths? If so, say hello. I did not know he was leaving until after the fact. I was told that he was frustrated with the reimbursement issues in our area.

Squalus? Isn't that a type of fish?

Yep... the genus for shark.