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We keep moving this vital bit of trivia from one place to another, (currently the first thing in the HPI which has the effect of cluttering things up, as the real HPI then starts on line two), and now it occurs to me, this should be part of the vitals. Could we have a box to enter the 1'stDLMP in the 'vitals' region. And could it be gender specific, so the box isn't even visible on a males chart?
Martin T. Sechrist, D.O. Striving for the "Outcome Oriented Medical Record".
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We put this in the Vital Signs Note along with the O2SAT and, if they are diabetic, a finger stick glucose reading.
Wayne New York, NY Hey, look! A Bandwagon! Let's jump on!
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I don't mean to be dense, but you are talking about the field for the objective data, "Physical Exam" right? That is where I also put the RBS and O2 sat. And it seems to me that those are two other items that should join the vitals as a little box for the MA to enter the number in. But maybe I am trying to make this more complicated than it should be. A few weeks ago someone suggested that we quit trying to add all these tweaks or it will be so complicated that it will never be bug free. At the moment that sounds like good advice.
Martin T. Sechrist, D.O. Striving for the "Outcome Oriented Medical Record".
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I would disagree. Adding tweaks, by definition, shouldn't cause more bugs. Tweaks are just that...little improvements that come about by using the program.
The vital signs section is another area that has been neglected for months. It would be easy to add more boxes, and it would be helpful if users could have a couple of options. There are places in the administrative section where things can be modified such as tracked data, etc. There is no reason one person couldn't have O2 sats while another had something else.
The VS note is not a very useful thing. If you put anything in it, it 1) hides your growth charts icon and 2) makes your vital signs printout look scrunched on the right.
Bert Pediatrics Brewer, Maine
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O2 sats are billable with some payers-a fixed place would be helpful. A place to enter more than one bp in a visit and the lmp option would be nice.
Vicki Roberts, MD Family Medicine of Southeast Missouri Sikeston, MO
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These are actually small improvements that I feel would be very helpful. I agree that there should be at least those to additional vital signs (o2sat, lmp).
We have yet to be paid yet on an O2SAT. I don't think they even reimbursed us on the patient that had early COPD. But I'd need to go back and check that.
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I agree, a couple of extra slots that could be trended w/ the VS would be useful for f/u of data. In one pateint you might be following Hgb, in another the PSA and for pts on coumadin - the INR and for diabetics or patients with CKD...
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I like that idea a lot. A vital sign box, to be defined on a case by case basis and able to print out a graph, HgBA1C on one patient, Creatinine or INR on the next. Wonderful idea.
Martin T. Sechrist, D.O. Striving for the "Outcome Oriented Medical Record".
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