Home Forums Discussions General Discussion Problems, Diagnoses/Encounters and PMH

Hi everyone,

I feel this will be my most important post ever. There are two issues to address here.

1. How everyone looks at the three basic tenants of information in a chart note. Debatable.

2. How it is presented in AC and how it can be used.

This will be long. I am sorry. I think it needs to be addressed mainly because AC (to their credit) will be making changes to how this is presented. First, let's start with what I/We think about the categories in the above subject. A lot of this is much more important to FP and Internal Medicine and Consultants, but it affects the pediatrician as well.

1. First, let us look at Problems. I think we will all agree that a Problem List is made up of problems that a patient has which may or may not need to be addressed at each visit. Problems may consist of hypercholesterolemia, hypertension, ADHD, Generalized Anxiety Disorder, Crohns. These are active problems. When a patient comes in for eczema, you may not talk about them, but the patient has those problems. At any visit, especially a physicial, you would likely address them. I would hope that FP (please just lump IM with FP -- sorry if I offend) would talk about these problems at a physical. Or maybe hypertension is so important, it is talked about even at a URI problem. The problem is the Summary sheet (the most poorly designed page or tab of AC is the only place to find these problems. And, unless you type them in, they are populated by Diagnoses. I always have to try it again, because it amazes me. I just gave George Washington an arm fracture diagnosis, and it is now an active problem. But, in six weeks, it will not longer be an active problem, it will be (according to AC if you change it), an inactive problem. I wouldn't even refer to it as that. I would now move it to PMH. I feel as though an inactive problem would be an active problem which has been treated and is now under control (hypertension now better with diet and exercise and medication) and would not be considered PMH (although one could argue this). Why? Because it has the potential to become active again. Take the arm fracture. Once fixed, it becomes PMH. It is important to note it, because it may one day impact your thinking (patient presents five years from now with left arm pain), but it is something you don't think about anymore.

Diagnoses are just that. To name some pediatric ones: chickenpox, eczema, otitis media, Hand/Foot/Mouth, Roseola. These are diagnosed, present, get better and are done. Some, like Chickenpox should definitely move to PMH. Very important when this patient is exposed to someone to know that. But, to put otitis media as a problem is not correct. Otitis media is not PMH. Chronic otitis is. Now, you can decide if chronic otitis media is an active problem. In pediatrics, it is. Every time I see a patient for otitis media, I have to decide do they need a consult or not. Strep throat is the perfect example. In the encounter list, it will either show up as pharyngitis or strep throat. Strep throat is diagnosed, treated with Pen-VK, and is gone. It is now automatically an ICD-10 code (with the descriptor) in encounters. It is not a problem. Again, chronic strep is. Maybe you need to be aware of the problem to rule out carrier or because he/she misses so much school with severe tonsillitis, that you need, again, to refer to ENT. The only argument would be if the patient developed Post-strep glomerulonephritis or Rheumtaic fever but, even then, it is listed in your encounters.

Past encounters: This has been my pet peeve since v1. The past encounters, arguably one of the most important section of the chart is populated AUTOMATICALLY by chief complaints. So a patient gives the chief complaint of "My legs have been hurting for the past four months," that is what shows up in past encounters. That is crazy. We have been taught since medical school that the chief complaint should be what the patient says in his or her own words. Where does that belong? In the chief complaint. Not in past encounters. You now diagnose this patient with RLS or Growing pains or even Leg pain. Maybe it is one leg, and you need to work them up for a malignancy. But, the encounter should show the diagnosis. In fact it should say diagnoses and not encounters. If you always use acute left otitis media as your ICD-10 code, you want that to show up there so you can see them at a glance and count them.

At the diagnosis field. That is where the diagnoses are put. The dropdown list is NOT problems. Again, Fifth's disease will now autopopulate the summary sheet as a problem and it is not a problem. I don't think we need to see the window which says, "The patient already has 'Fever' in their Problem List. Do you want to add it again?" It is NOT a problem. But, if you diagnose a patient with a URI or Fever, it will now populate your problem list in the summary sheet two, three, four times. I can see some advantage to adding it to your dropdown diagnoses as long as it can be removed especially if it adds a date. It would be cool to quickly see there are five ear infections. But, in general, I have kids with ADHD listed ten times. It's also nice to just grab the diagnosis, but it doesn't need to be duplicated.

Now, here is where workflow comes in. Because a list of diagnoses in the Problem List is not helpful to me, I have NEVER, EVER, EVER looked at that field. In fact, it just makes the summary for patient look bad. PMH and Problems should be entered manually by the physician. Problems don't crop up constantly even for the sickest patient, so it doesn't take much to add Crohns or HTN.

So, in summary, here are where these things are and what they mean and an added idea. PMH should be put in by the PCP and is something that usually has come and gone and means little to that patient's subsequent visits. We put 32 weeker as a PMH and a Problem, but the problem becomes inactive at a 18 months, the fact that they were a preemie means nothing. I would keep the fact that the baby was a preemie in PMH forever. The fact that they cannot turn over at four months is affected by the PMH or Problem List. The past encounters should be populated by your ICD-10 diagnosis not your chief complaint. Here is the key. Since for FP, especially, problems such as HTN, IDDM, Hypercholesterolemia, Parkinson's needs to be addressed frequently, it should be easy to see and easy to click on so that it moves to the assessment section easily. (maybe even everything you are doing for it moves over also -- propranolol, exercise). One shouldn't have to go to the Summary Sheet to see the problem list. Why not have problems located in the actual dropdown that says Problem List. You could select the ones you want. Or get rid of the Smoking Window and put problems there. The Smoking Window could even go in the Summary Sheet. The Summary Sheet needs a major overhaul. How many times have we recommended moving the Complete to default instead of the Due in the vaccine section at the bottom left? 30? 50? One less click. In fact, having that area be completely separate from where you enter vaccines is problematic.

The Problem List in Summary is so complicated these are the choices it gives:

Add
Resolve
Inactivate
Remove

And the dropdown list somehow has five options:

Show active problems only
Show resolved problems only
Show inactive problems only
Show resolved and inctive problems
Show all problems

Has anyone ever gone to summary sheet and selected Show resolved problems only? How is that helpful? The only way I would find it helpful would be to congratulate the patient. It is now inactive or PMH. To me, the only two things you would need are Active and Inactive, and they need to both show.

Again, there are two issues here. Which constitutes which especially an Inactive Problem vs PMH. But, a diagnosis is a diagnosis, and should always be in the encounter/diagnosis section (nowhere else). The other issue is where do you put them. I like to look at things as if it were a paper chart. It always mirrors how the electronic record should work. The first page you look at in a paper chart is the Face Page. It has the problems, the diagnoses, the allergies, etc. And, all three of these should be seen in AC on the first page. And, all three, (like Allergies), should be able to be edited without saving the chart.

I think the reason this occurs is AC doesn't have any physicians who work there who use the chart regularly. Jon Bertman was the last one, and I think he moved away from the day to day soon. And, beta testing isn't going to shed light on this. I have emailed Amazing Charts at least ten times in the past and gotten nowhere. Do AC programmers know what a "twip" is and how to fix it in ePrescribe admin section? Yes. Do, they have any idea the difference between PMH, Problems, Encounters, etc.? No. Should they? Maybe.

I would love to hear your comments. I think there will be many. This topic has NEVER been addressed on the board since I have been here.

Bert:
My viewpoint is a little different, but I think minor changes in AC could put a smile on both of our faces.
I like to stay on the most recent encounter page as much as possible. My solution would be to be able to edit what shows up in the drop-down problem list ON THIS PAGE, even it it needs to be done from the summary page. That would allow me to choose from a relatively small list of chosen active problems for diagnoses addressed this visit. I generally equate a problem to a codified diagnosis. We can talk semantics all day long as long as functionally we can customize AC to fit our practices. Not being able to edit what shows up on the drop-down list hampers my ability to use the program the way I would like. It has gotten worse with version 8 as it has allowed multiple problems with the SAME ICD-10 code to be listed in the drop-down (eg. I10 and its ilk). My staff would like to separate PMH into medical and surgical sections, but that can be done with current methods. I want the EHR to be better organized than paper and see no reason it cannot be.
I hope AC talks to us before wholesale changes in the program appearance.
Marlon

Yes, my problems are all ICD-10. But, leukemia with its ICD-10 is a problem, strep throat is not. Also, the Past Encounters need to be diagnoses. Whether the diagnosis of leukemia or strep throat is then chosen as a problem is up to you.

We are on the same page so to speak, pardon the pun. I think the best way would be to have a committee. I would love to see all of the dropdowns be problems. I mean you would choose them. The summary sheet is a mess. I can't make heads or tails out of CCD and CCR and Credence Clearwater Revival, etc. at the bottom right.

Bert
I like the idea of the drop down list showing Active problems on top and then all other problems below, this way easier to pick out those to repopulate the current encounter when dealing with chronic problems.
Would also like to see an active problem list be automatically populated into PMH section.
That being said wouldn't it be nice to be able to click on a Dx in the PMH section and have it automatically populate the Assessment section of the current visit, or maybe something like all active problems show up in Assessment section with a checkbox next to each to designate dealt with during that visit.

Oh and being able to notate a problem as chronic somewhere other than in the Summary Sheet area perhaps when a problem is entered into Assessment a check box to notate as chronic

Exactly. Actually, delete the summary tab. Nuke it.

Great idea. I had that in my mind. I can't believe I didn't put it in. It is so important to be able to address active problems at visits that clicking on lists already on the MRE is imperative. Just like you do with the letter writer. You can select meds or whatever, and it shows up in the letter. May not work the same way. I think the fist steps are to 1) most to agree with a Problem, PMH, PSH, Encounter, Chief Complaint is, and then for AC to have a REALLY good understanding of same. Because when they are devloping the application, they need to develop it in a way that reflects what the above mean and how it flows.

For years, I have had to have my MAs enter the chief complaint in the HPI and leave the CC field blank. I can then type in the diagnosis so it shows up in the Past Encounters field. I can't recall which version AC finally made Past Encounters the same everywhere. It used to be Past Visit History one place and Past Encounters in another.

Wow, I thought this would be like 50 posts long.

Board has been somewhat less active, must be the holidays

Thanks for your post Bert! You raise many important issues.

I agree that the Summary Sheet needs a major overhaul. I don?t use it at all except to check immunizations?I would much prefer that immunizations were included on the Most Recent Encounter tab?just a little button that would open them up would be enough. As much as possible I like to have everything accessible on one screen.

I don?t find a ?Problem List? helpful as a family doc. I use the PMH and Assessment windows. I keep a list of active problems in the Assessment window. When I finish my note I include the colon after the ICD-10 code to activate one or two diagnoses. These then serve as my diagnoses for billing purposes. I can avoid having AC add items to the Summary Sheet, like ?Viral Synd? by just typing it into the Assessment window. This way the items don?t populate over onto the Summary Sheet and aren?t sent to the patient portal.
Assessment window example:
# Viral syndrome (B34.9):
# DIABETES MELLITUS (E11.9)
# CHRONIC ANXIETY
# DEPRESSION
# FIBROMYALGIA
# OBESITY
# Hypothyroidism

In the Plan window I record my plan for each Assessment item in order as below. If I don?t deal with an item during a particular visit, I leave it blank.

Plan window example:
# Rest, fluids, stay warm, otc rx.
# ?.
# Restart counseling. Situation at home discussed.
RTO 2m

The PMH I use as a detailed repository of problems, active and inactive. When I do a physical I review the PMH to see if there are any issues that need to be addressed. Issues which are truly past history, inactive, and won?t become active in the future I put into a section at the bottom of my PMH under the heading ?Inactive Problems?. This would include things like, ?1994. Fracture, left radius.? I organize items using a system of # and a., b., c? As things change over time I can easily reorganize the PMH using this system. I add three special categories to the bottom of my PMH section: Patient Education Handouts (to record handouts that I?ve given to patients?I love handouts!), ?Consultants? (I use this to keep track of all the other doctors and caregivers that a patient sees), Notes (I use this to records various miscellaneous info including code status.

Past Medical History example:
# Morbid Obesity.
a. 8/02. Laparascopic Gastric Bypass (peak weight 363)
b. 2/2004. Reduction mammoplasty, abdominal panniculectomy with liposuction. She had areas under both breasts where the wounds took 8m to heal.
c. 8/08. Iron deficiency. 2012: Restarted on supplements.
# 1998: Diabetes mellitus. Saw Dr._______ once 6/00 but doesn?t want to return. 9/02: after bypass surgery her diabetes resolved.
a. 2011. Diabetes recurred due to weight gain
# Allergic rhinitis, seasonal
# Hypertension. 8/02: resolved after bypass surgery.
# 1988: chest pain secondary to esophageal spasm (clinically).
# Hypothyroidism.

Inactive Problems.
# 5/11. Release right trigger finger, 1st finger
# 5/08. Excision benign lump, left breast
# 1990: tubal ligation.
# 1986: cholecystectomy.

Patient Ed. Handouts
5/2014: DM.
8/15: Insomnia

Consultants.
Counselor: Mrs. Dolly ---------------
Gyn: Dr. -------------

Notes.
Patient since 1988.
Pap q3yr; due 2016
PMP lookup 12/15

The issue of Past Encounters populating with the c.c.?I have a simple work around. We record for c.c. something like: ?f/u bp? or ?physical; f/u DM? or ?UTI?. I record what the patient says in the HPI.

My system using the Assessment and PMH obviates any need for a ?Problem List?. No doubt there are a variety of solutions that others have worked out that fit their practice styles. One of the advantages of the AC design is that it allows each individual physician to customize the chart to their liking in many ways.

Hi John,

Thanks for your detailed response. It is very helpful and, as you say, points out the different work flows. It seems as though you rely almost solely on the PMH window. It is ironic that the PMH that is no longer relevant, you term Inactive Problems, just as I would think of the top half as Active Problems.

From your description, it would seem as though it would be helpful if that box were much larger. It would be easy to lose track of your notes or consultants without scrolling. Or do you use Enlarge Textbox? For your purposes, if I were AC and wanted to revamp the notes field and I wanted to enable your flow, I would likely make some changes to the PMH. I guess you could even refer to it as Past Medical History and Problems.

I am also wondering, given you document your diagnoses/problems in the assessment field and then talk about what you did in the plan. This seems very logical. But, do you retype in the problem you are addressing? Would it be good for the diagnoses or problem you document automatically populate the plan section? Or give you a check box to choose a preference. Maybe if there were a check box next to every diagnosis, you could check them if you want them to go the plan.

I have to say that your way of doing the CC wouldn't help me at all. I would argue that f/u BP is more helpful if that were the chief complaint, but the encounter field stated Hypertension or Hypertension, resolved. And, once again, that CC by the patient of "I think I have URI," not only looks terrible in the encounters, but could turn out to be Allergies.

Finally, I have questioned this several times, and it happened to me again today. Let's just start with a new patient so it is easy. I see them and diagnose them with Acute Bronchitis. Next time with Atopic Dermatitis. Now, if I need to get a CXR for Difficulty Breathing, and I select a diagnosis of Respiratory problems, the diagnosis is there for the CXR, but then goes away. But, should that be a diagnosis which stays? Or should it at least stay for future labs/radiographs?

in my past med history, i use a short key / template for each [pediatric] patient:

DIAGNOSTIC SUMMARY updated on [date of visit]

CHRONIC HEALTH CONCERNS / PROBLEMS: None

CHRONIC DAILY MEDICATIONS, (To the doctor's best information): None

PRIOR KNOWN SERIOUS ILLNESSES: None

PRIOR KNOWN SERIOUS INJURIES: None

PRIOR KNOWN HOSPITALIZATIONS OVERNIGHT: None

PRIOR KNOWN SURGERIES: None

PRIOR KNOWN ALLERGIES: None

LEARNING / DEVELOPMENTAL CONCERNS: None

OTHER:

ACUTE HEALTH CONCERNS / PROBLEMS / AND DATES SEEN:

Well Child Care: [in this section - each visit is noted- there might be a string of dates like so: 12/15/15; 10/7/15; 8/5/15...etc]
Eating / Feeding problem:
URI:
Strep:
Sinusitis:
Cough:
Congestion:
Rash:
Otitis:
Fever:
Diarrhea:
Constipation:
Gastroenteritis:
GU:
Conjunctivitis:
Injury:
Pain:
Concern:
Asthma:
Viral:

NEED TO REVIEW [i leave 'NEED TO REVIEW' if i do not get a newborn pregnancy history]
~
Pregnancy -
Maternal age when gave birth:
Received prenatal care - Trimester: 1
Gestation: Weeks
Complications pregnancy: No
Complications Labor: No
Delivery: Vaginal
Complications Delivery: No
Birth Weight:
Where Born:
Infant feeding: Breast for: ; then Bottle
During the first year of life: Growth and Development: normal; Serious Illness: no; Overnight Hospitalizations: no; Serious Injuries: no; Received medical specialty care: no; Any General health conditions of concern: no

**********

so as the visits recur- there will be a string of dates attached to acute problems, and serious issues will also be listed.
this is only as good as i remember to do it.
and it is not used for coding identification, but that is formally done in the diagnosis section
this helps me to see in one section most of what i need to know - or at least a good place to start

Wow, that is to be commended. You may need to give more detail on the Short Key. One thing that seems to be a common theme is that the PMH window or box seems to be used quite heavily by users.

These are great ideas and very helpful. I do want to make sure we don't in the mean time lose focus of part of idea of the thread. Which is there is PMH, PSH, Past Encounters and Problems, and they are not the same, and they certainly are not being put in the right place by AC and/or not showing up in a place where one can find it quickly.

short key is a software that i use from shortkeys.com
they do have a free limited version - short keys lite
it allows me to create and save templates for frequently used typed words / paragraphs - short or long.
i find this helpful in addition to amazing charts templates.

about entries into cc;
i also try to use patient's words.
however, since the past encounter tab will show the 'cc'
sometimes, and not all the time, i will use the patients own words; then will [bracket a couple of my own words]
ie, for a rash, it might be

rash; [scabies]
or rash; [atopic derm]

and as we know sometimes the chief complaint may not relate to the diagnosis in an obvious way

unable to sleep; [asthma]

Thank you, thank you, thank you, thank you, thank you............

The first person to ever acknowledge the folly of the CC populating the past encounters. I like your method. I do, as stated, something similar, which is to leave it blank and put the CC in the top line of the HPI. It's kind of funny. Even though CC is on the progress note, it is kind of cool that the final diagnosis is there in bold letters.

A little like the consultants who start with Assessment and Plan and then do the Subjective and Objective.

Which version changed the history information in ePrescribe to only give the date and not how long?

If everyone could collectively refuse the folly of "meaningful use", then programmers could get to work to really make the AC program meaningful and truly useful.
As it is, I use it pretty much like a spreadsheet -- but it isn't customizable in any way. I use none of the fancy features that got grafted onto a once-simple program.

Different doctors have different needs and styles depending on both personality of the doctor and patient characteristics. AC doesn't take any of that into account.

Any way you look at it, it beats EPIC for ease of use, and for readable notes.

Hi Tom,

I have long since felt that way, but I have stayed away from the topic as to not alienate those who went with MU. The problem for AC and every EMR vendor at the time was not that they would have lost customers, just not potential customer would have purchased AC without it.

It is very unfortunate. Plus, the government didn't make a big deal about the audits until after. What should have happened, even though many would have been unhappy, is the government should have given the money to new buyers but not "reimbursed" those who already had them without MU being in the play at all. MU has done more to screw up EMRs and care for patients.