Home Forums Discussions General Discussion Initial Entry of Past Medical History

This thread relates to the way we enter a patient's past history into Amazing Charts for the first time. This can occur when they present as a new patient, but I am more interested in the bulk entry of new data which occurs when you convert over from paper to Amazing Charts.

Adam and I started this discussion somewhere else, but decided it deserved its own thread. It started with Adam's statement:

I thought this was pretty impressive, and counter to my own experience. I asked him if he was entering all the patient's past history himself at the first encounter and he replied:

I agree with Adam completely, but I will confess that I can't enter this information myself in a timely manner, and this has been a major obstacle in switching from paper to EMR.

The process of auditing a thick paper chart and transferring the data to AC is not something I would do in the presence of the patient in the exam room.

When I started using AC, I tried to fill in the PMFSHx as I went, but I fell dreadfully behind, as it might take me five or ten extra minutes per patient to audit a thick chart and make sure all the pertinent data was transferred to Amazing Charts.

This doesn't sound like much, but if you only see twenty patients per day, and it only takes five minutes apiece, that still amounts to 100 extra minutes, which leaves you running over an hour and a half late by the end of the day.

My solution was to simply see the patient for the acute complaint, only filling in the information I gathered at that encounter. Then, that night, I would go back and audit the chart, and fill in the PMFSHx, dictating with Dragon NaturallySpeaking via my headset while I flipped through the patient's chart, page by page.

My workflow/production was preserved in this way, but my family life suffered for several months until I had entered so much of this data that the majority of the patients I saw already had it filled in.

Now, I only see about five patients a day who don't have this data filled in, and I just do it between encounters, before I move to the next patient.

Brian,
I enter my new patients' past medical history in the room, but do it a little differently. The patients are asked to fill out a form (prior to their first visit when possible) that includes their pmhx, pshx, family hx, soc. hx, last Pap, PSA, Cholesterol, colonoscopy etc. and all meds. I then simply transcribe their form onto AC with the patient looking on.
I repeat out loud what I am typing to be certain that the patient agrees with the history.
This takes a lot less time and, I think, is more likely to be accurate since the patients are not put on the spot to remember everything at the time.
Best,
Jim

Jim wrote:
Jim, I did not mention this above as per Brian's quotes, however I also read the data to the patient as I enter it. This gives them opportunity to correct me, and for me to remind them how healthy (or unhealthy) they really are.

This also gives me opportunity to get to know my patients better. No matter how well we know some of our chronically ill patients, there are always little pieces of the history that we forgot, forgot to write down, or never knew.

They also like to contribute to THEIR doctor getting to know them better, and who wouldn't like that!! So I see it as great P.R.

They are excited to know their charts are stored as .PDF images.

One patient made the mistake of asking me what I do for backups. GIVE ME A LITTLE MORE COWBELL!!! She got a run down on my whole backup strategy. She is my wife's counsin's wife (that doesn't really make her treating a family member, right?) So I figured I had a little latitude go off on the subject of backups.

To clarify, Brian:
I am not auditing their ENTIRE chart. No, I am entering the data from the LEFT side of our paper charts, i.e. med list and problem list and health maintenance flowsheet (paps, mammos, BMD, colo's, DRE's, cholesterols), narcotic flowsheets, diabetes flowsheets.

This is why I review with the patient as I go, because they undoubtedly remind me of a recent colonoscopy or a recent elevated cholesterol-->something recent that may not have made it onto my chronic problem list.

Like I said, there are some patients where time does not permit entering EVERYTHING in the room, but I am doing my best to try.

The first 4 weeks were HELLISH, and I didn't get home before 11pm.

However, the last 2 weeks have been 100% easier. You see, 75-80% of our thickest charts have been entered. So, I'm working on a lot of thinner charts and healthier people. The recent influenza mini-epidemic in Maine has been wonderful from a certain perspective--> many previously healthy patients are coming in to be evaluated. This allows me to do data entry that might not have been done for a long time.

Great information. Jibes with my experience. Thanks, Adam.

I hope a few more brave souls will share some of their experiences on this thread. Bert won't. He loves to remind me that 3 years ago, standing in front of a local Chinese restaurant, he told me to START paperless.

I was scared. I was broke.

I should have done it, look at the hassle it's caused me now. Ugh. So I've got tedonitis, I've got bleary eyes.

Bert is my mentor and I purposefully chose to ignore good advice. Stupid, Stupid, Stupid. Ah, but the good man hasn't let me down. He's there for me the whole time I'm converting...reminding me of the chinese place. But like a good big brother, he's there to pick me up when I fall.

I cheat a little. As a long time dragon user, I open my patients dragon file and cut and paste Their most recent PMH into AC.

I also fill in/update the PMFSH sections during the pt visit. When I went out solo over 2 yrs ago, I started up using AC, so essentially all my patients were new to the system. It was a lot easier to fill this in with the pt present then it was to try to read thru the scanned chart and transfer all the data over to the current note. This got me in the habit of filling in these sections as people came in and I generally am able to keep these files updated as they return because of habit, I guess. It is still amazing how many people will tell you they have no major medical problems when you are sitting there looking at their long list of cardiac and diabetic meds!

A little off subject, but how many of you are using the summary sheet in AC and for what do you use it? I often feel like it takes too long to flip back to the summary page for info during a visit and just rely on what I have in the current note section. Of course I also feel like the microwave is sometimes just too slow too cook things so maybe it's just me! We do use the summary sheet for tracked labs and immunizations, but that is generally it, although the nurses sometimes use it to pull off ICD9 codes for labs or referrals.

David,
I'm not using the Problem list under Summary tab at all.
I really wish the PMHX would carry onto the Summary tab, then the information would only be entered once/ updated once.

It's those darned ICD-9 codes that get in the way. Clearly a doctor did not build the ICD-9 list, billers/coders have organized to suit their needs. Makes sense since it was designed for disease registry data collection. It was never originally intended as the backbone for physician billing.

Interesting thread. I simply don't know what the problem is. I enter the PMH as I go. It takes me about three seconds to enter Asthma and chronic OMs. Oh wait...sorry guys...I'm a pediatrician. This is a joke.

@Soundhealth: I still think many don't use the option of an Excel spreadsheet for problem lists, meds, testings, results, etc. saved into the Imported Items section. This keeps you from flipping back and forth as you can open it and leave it top in the top right hand corner of your screen (depending on how big your screen is). You can edit it and save it back to the chart. Just as idea.

@Everyone: It would be simple to get the patient to do it or someone else if Instant Medical History weren't so complicated or expensive.

Somedays, I'd like to be a pediatrician. Try entering 10-15 items into PMHx for each patient. It would be fun to enter only 1 problem, or none.

Oh wait....I can't deal w/ screaming kids all day long. I can only deal w/ the occasional screamer.

I use the summary sheet, some, but only some. Where I have had trouble managing a patients lipids, I have begun to track them in the summary, but I also note in the imported items under item subject something like, "lipids-simvastatin 20mg". This helps me find what I need in the old labs quicker. In the summary page what I DO make an effort on is ALL IMMUNIZATIONS ours and outside ones, and infrequent labs like the PSA, TSH and HgbA1C or critical trends like a rising Creatinine.

I can totally understand not wanting typos, it is annoying. I am glad for the spell check though. I have the MA enter the initial PMHx from a form the patient had filled out and I review it, much faster than typing it in myself. I correct any errors that may have occurred. I also have templates for the babies, ,gyn and pregnant patients so that they are just filling in the Gravida, menarche, etc. I also incorporated in the template Last Pap, and last mammogram if applicaple and taught them how to keep it updated each visit. I can share the templates if anyone would like. For subsequent visits, I still review with patient for accuracy and new problems.

Adam,
I am confused. Don't you have to enter the PMH only once and then it keeps showing up with each subsequent encounter? When I do an annual exam or see a new patient I have a template which has:
SURGERIES:
MEDICAL:
INTERVENTIONS:
Pneumovax:
Tetanus:
Zostavax:
Mammogram:
Pap:
Bone Density Scan:
Colonoscopy:

My MA fills all of this in going from the written form the patient fills out before I ever see them. If they are diabetic I may also add EYE EXAM: or, if they have something else that needs tracking, such as Barret's I may add EGD:, etc.

Then every time I open a note, the information is right there. I can add to it ad lib if things have occured since I last saw the patient. This works well for me. I rarely look at the Summary window.

Leslie:

Adam and I have only started our conversion from paper to EMR relatively recently.

You have been at it long enough that I would guess that most of your established, active patients have already had their PMFSHx added.

The first couple of months of conversion, however, will find you filling in this information on almost everybody you see, which can take a long time. We were talking about the best way to do this.

Leslie,
thank you for that interesting tip, regarding your template.
Brian said it perfectly, we are still entering paper charts and transforming from paper to paperless.

Leslie,
I currently use the Summary Sheet on every patient visit.
I put the health maintenance items (Cholesterol with date and values, Bone Density Date, Colonoscopy Date, Pap Date, Mammogram Date, PSA Date and value, HgbA1c etc.) into the Directives on the Demographic page. This all shows up on the summary page. My receptionist shows the summary sheet to each patient on each visit and the patient then signs off that all is correct (diagnosis, meds, demographics and health maintenance).
Approximately half the time there is a change with something and it is corrected and a new Summary Sheet is printed and placed in the otherwise empty chart. This allows me to stay up to date on all of the above and reminds me to address the health maintenance with each and every vist. I love it.
Jim