Transcript Why EMR Notes Are “Hard to Understand”

History – Putting Enough In, Leaving the
Right Stuff Out, Making it Legible, &
Getting Done!
The Hardest Element to Document Effectively
- Making it Relatively Easy!
Bryan L. Goddard, M.D.
August 2010
Getting the History Right
 Before you enter the exam room
 Office Medication Reconciliation
 Importance of Chief Complaints
 Recording HPIs in the Exam Room
 Past, Family, & Social History – Different Standards
for the Chart and the Note!
 Review of Systems – Why we won’t “go there” until
we cover Preventive Services
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“Rooming” is more than “hostess-ing”
 Staff can set you up for success!
 Office medication reconciliation
 Carry forward current medications?
 If errors, verbal communication from nurse to
provider
 Vitals
 Chief Complaints
 Start with Reason for return (from last visit)
 Reason for visit as entered by scheduler
 Add new complaints voiced by patient
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Setting the agenda
 Before entering room, add “provider chief complaints”:
 From previous visit note
 From review of vitals
 From review of recent labs/DI
 From “sticky notes”
 From review of problem list & encounters list
 Set up HPIs – don’t put too much in them!
 After ice breakers,
 List chief complaints, and who brought them up
 Ask for any not on list
 Prioritize work for today’s visit
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Recording HPIs in exam room
 Sit with tablet & patient arranged in “therapeutic
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triangle”
Take histories in order of priorities
Enter data while patient talking – helps you not
interrupt, patients will reveal most of HPI before
you need to ask clarifying questions
Before moving to next HPI, if visit feels like 99214,
make sure you are building to 4 HPI points, PFSH,
and 2 ROS
Help patient analyze problems by completing each
HPI before moving on
Why, when, & how to enter PFSH
into structured modules
 Documentation standards for reimbursement only
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pertain to the content of today’s note.
“History verified” adds every piece of information
from structure module to today’s encounter!
Legally, primary care providers are supposed to
gather & maintain PFSH by at least the third visit.
Documenting PFSH is a requirement of Preventive
Service visits, but even a check mark will suffice if
content is stored in separate location of record
Specific recommendations follow:
Medical History
 This is simply a list of free text fields
 Browse feature helps make it easier to work with, e.g.
 Colonoscopy – Add date of last & findings
 Add repeat dates on same line
 Enables us to do search
 This can be great place to “inform” the Problem List
 Problem List has 174.4 Breast CA Upper Outer Quadrant
 Medical History has
o 6/15/2007 – T3, N2, M1 – Estrogen receptor negative,
o 8/25/2007 – Completed radiation therapy
o 12/16/2007 – Completed combination chemotherapy …
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Allergies/Intolerance
 This powers the drug/allergy checker
 Whenever possible, entries should be structured
 Treatment of allergic conditions should be progress
notes and Problem List
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Gyn & Ob Histories
 Expect changes as Ob-Gyn content upgraded!
 Currently muddle together Gyn and Preventive
 Ob history currently free text
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Surgical History
 Browse feature could help with appearance, but . . .
 Like Medical History, list of free text fields
 Date field can be very helpful
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Hospitalizations
 Browse feature could help with appearance, but . . .
 Like Medical History, list of free text fields
 Date field can be very helpful
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What should go where?
 Hospitalizations
 Past sentinel admissions, e.g. psychiatric admission
following suicide attempt
 All hospitalizations on-going
 Surgical History
 Major one-time cases
 Omit “trivial” procedures done in conjunction with
hospitalizations, e.g. chest tube following CABG
 Medical History
 Recurring procedures, e.g. colonoscopies
 Treatment details, including procedures, e.g. breast CA –
lumpectomy with axillary dissection, etc.
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Family History
 Documentation in note need only pertain to today’s
visit
 Something needs to be documented in this module
for Preventive Services, but level is at discretion of
PCG
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Social History
 Documentation in today’s note is “security through
obscurity,” i.e. sensitive details when recorded
become hard to find after many visits, however . . .
 Document sensitive details only to a level needed
for others to render care appropriately, e.g.
 “past alcohol abuse, last drink 2000” instead of
 “DUI, restraining order from first wife, & lost job
before going into rehab 10 years ago.”
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Review of Systems
 In general, you should be able to easily record this
as part of HPI without going to this section of note –
except for:
 99204 – New Patient, Moderate Complexity
 99205 – New Patient, High Complexity
 99215 – Established Patient, High Complexity
 99244 – Office Consultation, Moderate Complexity
 99245 – Office Consultation, High Complexity
 Preventive Services
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