Home Forums Discussions General Discussion question raised from the grave

This is a rehash of probably the very first post I wrote on this board. I ask it again, because I don't really have a clear answer.

What do we put in the various fields in an encounter?

I still think in terms of the Weed problem oriented medical record... Problem 1; diabetes. Subjective... Objective... Assessment. ..Plan.... When this method was introduced in the late 60's it went a long way towards organizing medical thought.

AC just does not seem to lend itself to this. The HPI ends up a mish-mosh of everything. The ROS only seems relevant during a comprehensive exam, or else just has random filler stuff added to tally up bullet points. The PMH is either a list of closed issues, or a mixture of those and a sort of problem list that is disorganized. The social history does not seem at all aimed towards the patient profile that is still taught.

So in summary, I now have several years of wonderfully stored electronic records that are less organized than my old notes and less useful. How do others organize their encounters and notes?

First we learn how to record patient encounters, and Weed deserves a Nobel. Then we have to learn how to do it well enough to please the lawyers. Finally, after we get a business to run, we have to learn how to do it well enough to fight the insurers.

I've gone from a half page dictation to 1 1/2 pages of some typing and a lot of clicking for even 99213 visits. My notes are bullet ridden like a mob hit.

Every few years I have to do a deposition, which is an hour or more going over my notes from the years of treating a patient. They have arthritis, and somehow have been injured, so the defendant wants to blame it on the arthritis. I've done one since I started using ehrs. I got to start with older dictated notes and see the transition to now. All I can say is that verbosity goes way up and the difficulty understanding what is happening with the patient goes up even higher.

David, I think it's impossible to do a good job of seeing the patient, make a perfect note, and also do what a family and business need.

My recommendation is to concentrate on the Plans if you can spend time anywhere. It's really all that matters when you look back. Active problems with your plans for each, will save lives and your butt. Most of everything else is for the lawyers and insurers.

Classic! I think I will take to quoting this one when it comes to questions about how to use AC.

I had this conversation in mind when the same question came up from a perspective AC user yesterday @ PRI_MED, and I showed him the Plan section and templates, and asked what he thought of building templates for the Plan section there were in the structure of Problem: Plan: , so that you could build templates of the most common problems, and then have your typical treatment plan[s] built into a template.

Since I'm a recovering systems engineer and not a clinician, I would like to hear from folks how viable this methodology is as a solution.

Dan,

Can you elaborate?

Dan, that is pretty much what I have done. But, my partners rag on me because they think the PMH is supposed to serve as the problem list. However, that means more or less keeping two separate lists updated. Mostly, what I do is do the best PMH I can, trying to organize it by problem gleaned from the Summary page, then fill the plan with my decision making, letting the orders and meds fall to the bottom because it is too much effort to weed them out. But it is cumbersome at best. I was much happier when on the front of the paper chart was a heavy card stock with the list of problems, and the inactive ones so noted. I think I missed fewer things.

I have found my notes are better organized than the Word document/dragon notes I transitioned from, and I think for several reasons.

In AC the med list, once entered, is much easier to reproduce and change and review, and print up at each visit, if needed. Also the drug interaction checker has saved unnecessary phone calls from the pharmacist.

The Allergy list is easy to find, add to or delete and the automatic pop up warning if you prescribe a drug on the list is helpful. However, I do put meds that are not true allergies but just intolerable in there as well, so it is not for me just a true representation of "allergic meds".

I never wipe out the PMHx section and will often add or update or rectify the list during the annual or if I remember during a f/u after a diagnostic test or hospital stay. I was able to really clean up the PMHx when I transitioned from the Word document charting, and I took Dr Grauman's advice and did an initial visit before I saw the patient for the first time starting the AC chart. I did all the data entry myself, so my PMHx sections on all my 1000 patients are quite accurate. I am finding this section to be quite helpful before each visit, I print up on paper the most recent note and the PMHx section perusal allows me to get a snapshot before each visit of the up to 20 years of data organized in a somewhat cogent fashion. I use this printed paper note during the exam to take notes on and refer to during the visit. I did accidentally wipe out the PMHx section on a complicated long standing patient--I have only done this once, as it was slightly painful to re-enter all the info again.

Now the Assessment section has given me a much better and deeper understanding of what the front office gals do with coding and has allowed me to be much more accurate of getting the correct codes for the visit--before if I could not find and circle on the old paper super bill I would just write in the diagnosis and let the gals find it, but the new way is better and more accurate, plus I like the code finder.

I agree with Dan, a lot of the stuff in the HPI is fluff and the meat of the note should be in the plan, as this is what gets sent to the patient in the summary or what I refer to just to remind myself what I did on the previous visit, but I have put more energy and effort in to the plan and dragon has been extremely helpful for this.

I think the vaccine section and health maintenance items have been extremely helpful as my % of shingles and Tdaps and pneumovax administration has gone up considerably with these reminders.

Overall the stuff that is not terribly helpful--the ROS and Exams I template out and dictate over the abnormals on the fulls, then for f/u visit I have templates for my quick sick exams and INR exams and quick ROS for these as well.

So I dragon the HPI and Plan, and modify the PMHx at least once a year during the annual, and template the fluffy repetitive stuff.

I think that's the bottom line. I don't have a partner problem, so I guess you need to make a compromise on what will help everyone miss fewer things.

I look at PMHx as old, settled things that could possibly affect a future problem, but are not a problem now. They had an appendectomy 26 years ago, but it only means something if they start to have belly pain. It's not a problem now.

I don't have to carry all problems in my assessment and plan, since I don't do primary care. But diabetes and hypertension will often overlap with their arthritis diagnosis, so I put it in my assessment, keep it in my active problems, talk about it, and ask the patient to followup with their primary. I don't feel shy about adding those kind of peripheral active problems to my claims.

For plans, I follow the active problems, most of which are diagnoses, and some are worries, intuitions, and hunches, like "Monitor for Lupus", "Fall Risk", "Family Stress". The problems I'm worried about today, are exactly the things I don't want us to miss at the next visit.

Bert, not sure what you want expanded.

I think we are in this messy transition from analog to digital medicine and feel like ugly ducklings. It's like when we got our first digital cameras and didn't have to be so careful about clicking away. Easy to get a lot of notes that are harder to explain.

I think I have one foot in the 20th century and the other in the 21st, I cannot quite let go of having a piece of paper with data to take notes on, but yet the ability of having the capacity to print up BP's, Weights, med list, at a punch of a button and sending prescriptions without any wires attached to the PC has given me a similar sensation of seeing a jet fly. I still can't wrap my brain around the fact that so much metal can get airborne. I think in addition to the EHR, are all of the other tools just becoming available. Right now we have over 300 gauges of railroad tracks to carry this EHR data on and the beauty of something like Updox or the fax thing Bert talks about, has allowed to patch that ill fitting system to make it work a bit better for now, in addition of interconnecting in a Governmental allowable transmittal of electronic data to and fro with patients. I have always thought of this stressful period of transitioning from paper to the electronic health record as just that, but I think Dan is right, it is medicine itself transitioning.
During this transition, I think the old ways still have merit, what do you want the note to do for you and how does it best help you? KISS--keep it simple son!!!