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).
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 –
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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 |