Home Forums Discussions Problems How to find un-documented encounters

My partner has a propensity to close notes without saving them. Most of the time, this is discovered and we can resurrect the note from someone's deleted items. However, there have been occasions when we discover that patient X was seen last week but there is no note in AC for patient X for that date. Is there a report I can run twice a week or so to 'catch' all these un-documented notes and have my partner complete them before he forgets what the diagnosis and treatment were? Perhaps something like-- patients who were scheduled this week but who don't have a note for this week?

Dear A.J.:

I would say, no, this can't be done in AC--at least V6.0.10 which I use. In "Reports" there are only 4 search fields related to the Schedule. None would enable such a report to be generated. I would think the simplest system might by for Dr. X's nurse or secretary to double check on a daily basis. This could be done quite quickly by pulling up the schedule for the prior day and then pulling up each chart in the day's schedule to see if there's a corresponding note. It's said that a good habit is established in a month. So hopefully you might only need to do this for a month. When Dr. X finally gets out of the habit of prematurely closing charts--celebrate and take him/her out to dinner. :-)

John

AJ, I would generally agree with John. You can only run a report to find an encounter if the chart was signed. If you delete it before signing, then I don't see how you can run a report.
I can envision some work-arounds, but all would involve significant work; probably more work than the daily "double check" John describes.
Hasn't your partner been doing this for a year? Isn't it time he learns to stop deleting charts before signing them?
Maybe he or she should be doing the double check at the end of the day....then he might decide it is easier to just be more careful not to delete them.

First of all, this is sad. Very sad. I would think that anyone who cared about the practice would want to do sign and save his notes. This isn't memorizing macros or CTRL - Shift combinations, this is basic, click sign.

OK, that being said, here is how you fix it. Any MA, and I hope you use MAs and you don't have to triage and forward your own charts. But, I doubt he would be capable of doing CTRL + N. (I don't mean that in a demeaning way -- just helps with the solution).

OK, so your MA does his/her part of it and forward the chart to him. At this point, she opens the chart again and chooses print current note as unsaved draft. It looks better than the others. (You can print this at any time even before forwarding it, just thought it would be safer this way, and everyone would get into a routine). Put this note in a pile. At the end of the day, put the stack of notes in a special container.

It should say in big, bold letters THESE ARE THE PATIENTS YOU SAW TODAY. MAKE SURE THERE IS A NOTE SAVED ON THEM!

Tip: Make a copy for yourself. At the end of the day, you do a query on progress notes = 01/30/2013. You will get a list of all patients seen that day. You take your printed. After mentally filtering yours out, set aside the notes that do not have a corresponding saved note. These are the ones that will need to be redone. Have him put 25 cents in a glass jar for candy for the rest of the office for each.

Wow! I thought that was a GREAT answer. He must be signing them all now, lol.

On a serious note, the close chart and foreward chart selections under File are right next to each other, which I personally think is insane, because I routinely click the File dropdown selections in order to foreward a chart I am not able to complete in the exam room. Every once in a while I accidentally click close chart and my heart sinks because it is gone. I asked tech support why the two are right next to each other and they could not give me a good explanation. Consider how many clicks we have to go through to save something to the chart or to print the instructions and CCD. Why is there not some sort of double check asking if we really want to close the chart?

Mel,
That is why I trained myself to NEVER forward charts from the drop down menu, and ALWAYS forward with the shortcut "Ctrl-S".

Exactly. I have never in over ten years used the File menu. Plus, it is not a support issue. They are not going to know or care, because that is a developer issue. It is like paying Microsoft Support $257 to ask why is Reply on the left of Forward. They will just tell you it just is and take the money.

The other method is to use Forward Chart in bottom right. The advantage to this is you can type any message in the message box. It will not show up in the chart, but it will when you highlight it. So, you could forward the chart with the note: Need to research types of headaches due to symptoms.

Those are very good points. Thank you.

AJ,
The bottom line is that your partner needs to do it right, no substitute for that. Does he perform all his daily work in such an irresponsible way? I would be concerned if he can't learn this.