Wiki Cc & hpi

[btadlock1]

Does anyone know the answer to this?:

*I know that CC, ROS, and HPI can be listed seperately, or can be included in an HPI description.
*I also know that the ROS is the patient's positive and negative responses to questions about the affected system, which is described in the HPI/CC and other related systems.
*And, I'm aware of the fact that the CC must be recorded by the physician.
Now here's a scenario to consider:

A practice uses an EHR template that includes a section labeled "Chief Complaint", followed by a section labled "History of present illness." The CC section is often populated by 're-recording' (sometimes copy/pasted or copy/forward). The provider does personally record the HPI portion, which is usually detailed enough to reiterate the CC. But, in one instance, the CC forwarded from the nursing entries doesn't match the ROS, HPI, Exam, or Plan.

"CC: pt here for follow up on labs for impotence; sore throat; congestion; cough."
Then the ROS and exam only focus on the ED, and actually say "No sore throat, No nasal congestion", and "no cough", and "Lungs CTA" and "no pharyngeal erythema".

Now for my questions:
Should we have the field carried over from nursing documentation labeled as "CC", when by definition, the info doesn't meet the documentation guidelines for a CC?

Secondly, what do you make of the nursing CC not matching the content recorded by the MD? Does it matter?

 

[Mojo]

Hi Brandi,

The copy forward function can be a nightmare for risk management. Errors in documentation can be carried forward and I don't think the nursing CC should be populated into the CC field. Can another field be created for the provider CC?

To answer your second question, I think accurate documentation is paramount. A malpractice attorney would salivate over this conflicting documentation. I can hear an auditor, tsk, tsk, tsking. Hopefully, with your feedback, education and examples, the EHR can be tweaked and nursing can be more vigilant with their charting. Is the EHR new to the practice?

 

[btadlock1]

It's relatively new, but I think the real problem is that the doctors are trying too hard to meet the guidelines most of the time, now that they're entering information into populated fields, rather than writing out old-fashioned SOAP notes. The latter were more natural, and didn't have so much ease in over-documenting based on the patients' medical needs. It's easy to provide HPI elements, for example, by writing a short, descriptive phrase about what the doctor knows about the history and nature of the presenting problem. The charts I've reviewed recently seem to indicate a widespread struggle with how to incorporate a SOAP note into an EMR template. It's like they're trying to make it harder than it is - there's always a reasonable amount of quality information - enough for the note to meet the right requirements for medically necessary services; but there's a bunch of useless information randomly dispersed through the note, like they feel compelled to use the field, but don't know what to put there. I'm going to do some educating on what purpose the HPI elements serve, so that they'll be used appropriately, instead of compulsively. I'm also going to go over the requirements for each level, so that it's clear that they don't have to fill every blank just to fill it.

I wonder: Do EMR's have the ability to be styled as the SOAP notes that some doctors are used to? I can see how it would be hard to learn EMR, even if you're computer/tech savvy. It's not the difference between just writing and typing for them; they're having to change to a completely new style of writing, and it doesn't mesh with their old style. I bet it would be like: being used to writing everything using Shakespearean language, but then one day, someone tells you to start writing it all in Gangster-rap format. And learn a new computer program. The more I think about it, that has to suck. Now I feel bad for them!