Document faster??

[MedDoc4]

I've been trying to shave time documenting my HPIs and have essentially abandoned the paragraph format. Now I'm using a bullet-point style but others in my office think it loses context..

My example:
- Onset:
- Context:
- Symptoms:
- Timing:
- Severity:
- Aggravating:
- Alleviating:
- ROS:

I think it saves time and makes it easier for billers. What do you think? How do you prefer to document a new problem quickly?

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[VA Hopeful Dr]

If free typing, paragraph. If template, more bullet points.

 

[deleted87716]

Combination. For acute problems, I'll use the EHR template (e.g., bullet points) and embellish with free text. My chronic problem HPIs are pretty much free text (copied forward, with modifications). I can type around 80 WPM, FWIW.

 

[FrustratedFamDoc]

Have a standard template for my office notes. I dictate my HPI/Plan and length depends on how complex the visit was. The software I use is pretty good and I can have a pretty good HPI done in less than 30-45 seconds. Most notes are done in 2-3 minutes. I'm envious of people that can type. Without my fancy schmancy dictation, I'm dead in the water on anything more than a moderately busy day.

 

[SLC]

I use a mix of the two, for acute or first time problems I’ll use a template very similar to yours. It’s a good template because Medicare requires at least 4 approved modifiers (the bullet-points you have) for at least one problem you address; so writing them out explicitly isn’t a bad idea.

I document all notes to a 99214 so I can select that code if needed. Which saves time and headache and gives flexibility to not really have to think about it much during the encounter.

Basically I use the HPI template and a 2+ system ROS to ensure my HPI/ROSwill support a 99214, ensure there’s at least some PFSHx, and generally explicitly state “new problem” or “chronic problem well/not well controlled” as my opening sentence in the A/P. The decide billing code based on complexity and if it ends up being 99214 I can just select it cause the note will support it. I can then just do whatever exam seems pertinent and let the actual number/complexity of problems determine the billing code.

Using that formula and macros for exam and ROS, I can generally complete most notes in real-time. Signed before I even leave the exam room.

 

[galactus]

I free type and smartphrase (Epic) everything, and use/memorize every hot key possible on the EMR. I'd like to thank Mavis Beacon and Mario for teaching me how to type at around 80-90 WPM, and a lot of computer gaming.

 

[door_to_balloon_knot]

I free type and smartphrase (Epic) everything, and use/memorize every hot key possible on the EMR. I'd like to thank Mavis Beacon and Mario for teaching me how to type at around 80-90 WPM, and a lot of computer gaming.

This is the way

 

[deleted87716]

This is the way

Yep. I do the same.

 

[wavecrasher111]

I use a mix of the two, for acute or first time problems I’ll use a template very similar to yours. It’s a good template because Medicare requires at least 4 approved modifiers (the bullet-points you have) for at least one problem you address; so writing them out explicitly isn’t a bad idea.

I document all notes to a 99214 so I can select that code if needed. Which saves time and headache and gives flexibility to not really have to think about it much during the encounter.

Basically I use the HPI template and a 2+ system ROS to ensure my HPI/ROSwill support a 99214, ensure there’s at least some PFSHx, and generally explicitly state “new problem” or “chronic problem well/not well controlled” as my opening sentence in the A/P. The decide billing code based on complexity and if it ends up being 99214 I can just select it cause the note will support it. I can then just do whatever exam seems pertinent and let the actual number/complexity of problems determine the billing code.

Using that formula and macros for exam and ROS, I can generally complete most notes in real-time. Signed before I even leave the exam room.

Won’t the new fee schedule enable docs to not have to focus on certain HPI/ROS to support a certain billing level?

 

[door_to_balloon_knot]

Won’t the new fee schedule enable docs to not have to focus on certain HPI/ROS to support a certain billing level?

Yes. All based on MDM. Better know your problem complexity/ data/ risk kiddos.

That said, should still document as much or as little (more likely) needed to CYA. Pretty sure notes in the future are going to be like trying to piece together what a whole puzzle looks like when all you have are 2-3 pieces.

 

[VA Hopeful Dr]

Yes. All based on MDM. Better know your problem complexity/ data/ risk kiddos.

That said, should still document as much or as little (more likely) needed to CYA. Pretty sure notes in the future are going to be like trying to piece together what a whole puzzle looks like when all you have are 2-3 pieces.

Meh. I rarely read other people's HPI, ROS, PE. Most people at least in my area put anything important in the A/P.

 

[Sardonix]

Meh. I rarely read other people's HPI, ROS, PE. Most people at least in my area put anything important in the A/P.

Mmm, ah, yes, the thing I suck most at right now as an intern. Wondrous.

 

[door_to_balloon_knot]

Meh. I rarely read other people's HPI, ROS, PE. Most people at least in my area put anything important in the A/P.

Hey! I like prose and the small clues that lead to a deduction ok

But sometimes it’s:

“HPI: Abdominal pain x 3 days. No N/V/D.

Then ...

A/P: Pyelonephritis - cipro x 7 days.”

No labs or anything.
I’m left with all sorts of WAT.

 

[SLC]

Won’t the new fee schedule enable docs to not have to focus on certain HPI/ROS to support a certain billing level?

I suppose so, but that’s how I chart, it’s how I have ever since I was an intern. It’s not burdensome, and it gets the job done. I won’t look to change unless I see a critical need.