Chart Keeping in Clinic

Clinic Record Keeping

The main intention of writing notes is to concisely RECORD AND COMMUNICATE the findings and your thoughts from the encounter. Always aim for quality- clarity, organization, thoughtfulness, NOT quantity nor data hording.  Use this task as a way to help you put the case together after seeing the pt. It is important for all of us in clinic to adapt the same standard template in writing notes- this allows for safe communication in patient coverage. Avoid carrying over large chunks of unrefreshed problem lists, or unreviewed copy and pasted labs/data on your notes. Try to limit clinic notes to at most 2-3 pages printed. “Run-on” notes that goes on way too long, impairs the ability for others (and probably yourself) to grasp the big clinical picture.  We recommend that you keep your health maintenance check list on the bottom of your note (not in your problem list) so it is not distracting, and is simply a good reminder at the end of your visit. Refer also to more info on EMR clinic note writing in the newest Eclipsys Guide (now on the columbiaresident website).

 

**Please take 54 minutes to watch this great Grand Rounds from Dr. Larry Weed introducing the Problem Oriented Format in 1971, many of his comments remain relevant today.  

 

ALL CLINIC NOTES SHOULD BE WRITTEN AND SENT TO ATTENDING FOR COSIGNATURE IMMEDIATELY AFTER THE CLINICAL ENCOUNTER. Delayed note recording at the end of the clinic session may result in missing content.

The Standard AIM note template

Please use the AMB AIM Primary Provider Note for your regular f/u visit

Standard AIM PCP template –

o   Coding Box of major diagnosis- Please ICD code the pt’s major medical conditions (CAD, CHF, DM etc). Do not click to display this list on your note, this coding of will mainly help with billing and generating your panel’s disease registry.  

o   THE 1st free text BOX (Problem List, CC, HPI, ROS, FMhx/Sochx )

1.      Problem list- the goal of the problem oriented charting (introduced by Dr. Lawrence Weed) is to concisely summarize the patient’s overall medical hx, allowing the note reader to quickly understand who the pt is with a brief review of this introductory summary. A “problem” is any established diagnosis (like CHF, Depression, DM), physical finding (hemiparesis, mass in abdomen), or symptom  (cough, dyspepsia). Adding descriptors to the problem is important, for example- “CHF” by itself is not very helpful, but “ischemic CHF Class 3 with EF of 20% with recurrent hospitalization” paints a clearer picture of the pt. The problem list with it’s informative narratives should be reviewed, updated, and “weeded” at each visit)

                                    -Active  Problems -sort the problems up and down by level of activity.                         

                                    -Inactive Problems  Pmhx and Psurghx

2.      Chief complaint/HPI/Interim History/ ROS – record CC, relevant HPI and pertinents, and a general survey of the pt’s health with ROS.

3.      Social hx

4.      Family hx

o   Med Allergy/ADR (this is autocopied from eclipsys allergy section)

o   Med list –(this autopopulates from Eclipsys) always try to reconcile the list with patient’s bottles, delete old and unnecessary meds.  Your role as a PCP is to keep the list clean so the pt understands what is important to take each day.

o   2nd free text box- Physical Exam - import ambulatory vital signs/BMI in one horizontal line by using F6 “current VS” button. Then record your physical findings.

o   3rd free text box-data text box (no need to click and copy large chunks of data into your note, it’s already in the EMR). Use this free text box to highlight important and new data.  No need to carry old and miscellaneous results to perpetuity. Do not clutter your data box with old stress test or echo (if it is truly relevant, that info should be summarized in your problem list) 

o   4th free text box-Assessment –This is the most important part of every note, it derives from your cognitive processing of the information obtained by history, exam, and record review. When written well, this will help others quickly understand  (w 2-3 sentences) who the pt is, why they were seen, what you found, what you think is going on.

o   Problem/Plan- prioritize the most acute problems and chief complaints on the top of the management list..  Describe your thought process and your plan for diagnosis or management.

o   Health Maintenance Tracking- record indicated vaccine, mammo, pap, colon, advane directives info etc

 

Note sample