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In my paper charts,if a patient has allergic rhinitis, for example, I write in which allergens they react to; for recently post menopausal women I indicate the date of the final menstrual period; for people with coronary artery disease, I write in whether they've had an MI, when etc...
Also, in my notes, I don't just list problems, I comment on them; if I do that with AC, the problems aren't recognized and the ICD codes don't get transferred to the fee slip.
Does anyone have ways around these problems?
Lisa D

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I have the same question after fooling with the demo.

I guess the answer is to make those comments in the PMH section, but not on the problem list.

It will be some duplication, but there is great benefit in having the problem list entry succinct so it can be searched. Since this information will change little over time, it will require no editing or light editing after the effort of the initial entry.

Let the problem list be the minimum diagnosis + ICD-9 and use the PMH text box for maore of a narrative, expanded description.


Jacques Guillot, MD

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