Home Forums Discussions General Discussion Having patients complete HPI and ROS

Our two-man, paper chart-based practice continues to evaluate and consider EMR systems, and like what we have learned about AC. However, it appears that office staff are the ones who must enter HPI and ROS for patients' visits in AC. In our current pen&paper system, that work is primarily done by the patients using templates.
Is it possible for this to happen in AC, or is that an efficiency we will lose in progressing to AC?
Vance

Dear Vance:

I'm a solo family doc and have been using AC for about 9 months. There are various ways to handle EMR documentation with AC. We give patient's a paper questionnaire when they come in for physicals or followups to get the history. I record the HPI myself as I'm talking with the patient. The ROS I record using a template--two keystrokes. Then based on the paper form the patient has completed I can modify the template. It's pretty quick. Some offices have their medical assistant type in the HPI info as they get and enter vital signs. Another approach is to use a system like Instant Medical History which can be integrated with AC.

Once you get your templates and systems established and get used to using the system you can document your visit pretty quickly. With AC I document much more completely than I used to do on paper and spend less time doing it. Compared to most other EMR's, AC has been designed for ease of use. This is not to say that transition from paper to bits/bites is easy!

Vance, I aggree with John - you can do this quickly and I have pt. fill out ROS, HPI, etc at first visit which I then enter. The next visit I just make changes to the note. It is important to remember that for CPT coding it is assumed that you physically review and verify the ROS, HPI yourself and for me I do this quickly as I talk with them (keeping in mind I type fast).

I realize that things like Instant Medical History is good and we would all like our pt. to be accurate, but I find so many things/symptoms/diseases/surgeries are wrong in the pt. supplied history.

Vance,

Agree with the above. There are also programs available outside of AC that can facilitate populating most if not all of the left side of the page in AC. That is CC, HCC, ROS, PMH, SOC HX, FM HX, etc. I don't use these. These programs are Instant medical history and Phresia. There may be others as well.

Tom

Thanks your responses are helpful and encouraging.