Home Forums Discussions General Discussion New Feature AC Design Feedback

Hi,

I am Kim a business analyst with Amazing Charts. I will be working on some new features and would like to get your feedback as I work through the designs.

My current project is documenting functional and mental status which we are required to include in transition of care documents for Interoperability.

Where are you documenting this today?
Do they each need their own section in the Most Recent Encounter?
Any additional comments?

Thanks in advance for your feedback.

Kim

I am not a good person to ask. But, maybe I am since I don't want either. My guess is most people will want it on the MRE. I think if AC had a face sheet, which I have advocated for 11 years, it would go there. But, AC has sort of a convoluted face sheet that they call summary, and it isn't the first thing to pop up.

Kim
Possibly a better way would be to do a Skype session with some power users or paste some ideas on this board...it is hard for be to visualize what you want after a hard days work...

Kim,
Thanks very much for asking. Many of us really appreciate the simple fact that you are asking us design questions. That has not taken place too much on the board here, so please don't get discouraged if you do not get a lot of responses. Please keep asking, and hopefully people will begin to give you good feedback.

As to the specific issue you raise, I would suggest that you begin with the following:
"How many of you document functional and mental status in your notes?"
If so, where do currently record this information?

I say that because it is not something I routinely record. I am not sure how many others do. (Of course that may change with evolving CMS requirements).

I record this as part of the physical exam. The amount of detail depends on how pertinent they are to that particular patient (post stroke, dementia, other brain injury, pre-op evaluation, etc) or whether there are positive findings that need to be documented.
Not sure about whether they need a separate section.
I would be more interested in a separate section for past medical history that could be updated at any time (meaning whenever we get new information) and not just during an encounter.
Thank you.

Kim, I responded to the email sent out by PRODUCT EAR but, I will post here also.
My doctor documents Functional and Mental Status on all Medicare Wellness visits. She will also document both if not one when it applies to the patients office visit. If the patient comes in with memory or reported functional issues, she will document the status in the chart.
She documents both in the REVIEW OF SYSTEMS using a template that she has made. We use a MINI MENTAL STATE EXAM form for the Mental Status. That form, of course, is scanned into the chart along with the documentation of the results in the REVIEW OF SYSTEMS.
Thank You
Allison
Healthy Concepts Family Practice

Not sure about whether they need a separate section.
I would be more interested in a separate section for past medical history that could be updated at any time (meaning whenever we get new information) and not just during an encounter.
Thank you.

I agree Dr STEPHENS. Every time I learn of more PMH not during the patient visit, we generate a new encounter called "PMH" and enter the data and sign off. The problem is this has consequences to the compliance and reporting since it LOOKS like it was a visit rather than just the addition of new information.

Thanks for asking - I did not get the product ear eamil
I document functional status - ADLs and IADLS under ROS
and also under a scanned document ' howsyourhealth ' which is a health risk assessment under 'other' in scanned itemss
I document mental status under PE , for dementia usually MOCA score and then scan in item, for MS for psychiatric illness also under PE

If they needed to go somewhere under MRE so they can be made granular, then I suggest a tab under ROS for functional status and tab under PE for Mental status exam

are you saying that they need to be doumemented as drop down menu picks for TOC?
Lynn

I think most of us use some sort of standardized scoring tool like the ADL, IADL, MMS and MOCA mentioned above.

A tool like a form that could accelerate documentation with drop down answers and auto addition of points would be useful. Could this be built into practice documents and when completed saved to a to folder in imported items in the patient record? The contents of that folder could be (? user preference) defined as part of the formal health record?

This approach would work well for other standardized scoring tools as well such as ASQ developmental screening, AUDIT scores for alcohol use, Beck Depression Inventory etc.

This would be a nicely scale-able and adaptable solution for different practice types and new requirements.

Good Luck and thanks!

Patrick Barry

It has not worked very intuitively in AC. I've made some templates, but for ease of use I tend to use a work-around with a paper form scanned it. I'd like to see a better solution in AC