Zenman1

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Oct 31, 2013
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Came in to work on Sunday and met five other providers trying to catch up on notes. Monday morning AHLTA goes down immediately prior to seeing my 1st patient and stays down for all eleven patients, finally coming back online right at 1630, which was exactly the time I walked away from my desk and went home.

I have one question. What is the shortest, most concise, intake and follow-up note that can be made, and that satisfies every frick'n person, agency, or government entity that has a hand in this field? I already use a Word document template but am open to any suggestions.
 

DrMetal

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What is the shortest, most concise, intake and follow-up note that can be made, and that satisfies every frick'n person, agency, or government entity that has a hand in this field? I already use a Word document template but am open to any suggestions.
There likely isn't one. This is the quintessential problem of the EMR . . . no template satisfies all. I'd say, make a template that satisfies your little world (your clinic, your department, etc) . . .the rest of the world should/could be able to read it and figure it out. Word documents are great---easy to format, easy to write in (even in real time), easy to copy and paste into AHTLA.
 

Shikima

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Create simple documents based on a usual H&P and PN, and just copy and paste would be my recommendation. Don't go overboard with the documentation and keep it short and sweet. Not sure about all the added details for med lists, vitals, blahblahblah... hope this can be helpful.
 

SuperSoccer19

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There is a lot of nonsense that the military requires you to include in your note that you probably will not be asking and really don't need to know to do your job well...and don't get me started on HEDIS measures and the crazy idea that sometimes clinical judgement is more important then a measure. Recently, I met with a program director who asked, "how are you able to ask all these questions and document it in a 20-30 min EST?" My response: "I don't and I don't care."

I have a good word template that I created the end of residency and modify at each command to meet their peer review standards. One thing you may want to look at is your hospital attending's peer review sheet to help with this. Personally, I think the only thing that is really important is that a future provider can clearly read your note and figure out what you did any why. The more info in a note, the harder it is to read and get that information. Often the content is not important. For instance, if you find yourself writing out a lot of the he-said-she-said drama in detail, consider just simply saying, "Patient reported anxiety symptoms secondary to partner relationship problems" as opposed to giving the specifics of the drama (although it would be helpful to define the anxiety symptoms). All notes obviously need some comment as to why you don't think the patient is going to kill himself or someone else--not that you can really predict this...

One thing that has really sped up my note writing days has been to keep it short and to actually type during encounters. If you can do this while making good eye contact and showing empathy at appropriate times, give it a type. I've asked patients if it bothers them and most say no or actually like that I am getting their concerns in the record in the moment so it is accurate.

On another note, I am currently looking at civilian jobs and between this and getting records from outside providers it is AMAZING how much shorter most of their notes are compared to ours. Some are paper and you simply check the system or fill in the blank with pen. Others are just a few sentences, but get the point across. Others have no info and suck, but if you have too much info in a literary work of art it also doesn't really help much either. If you want me to send you the template i use i can email it. May not be any better then yours.
 
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HighPriest

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As mentioned, I always write my notes with the specific idea that the next guy reading it will know what my thought process was. Patient states x. pertinent positives. negatives. exam. A/P. meat and potatoes, as much as is possible. I could not possibly give less %&Ks about what the military wants in the note. This is an EMR, it's purpose is to store and convey pertinent medical information to other providers. It's different on the outside due to billing and medical-legal issues, but I have absolutely no qualms with blowing off some civilian pencil pusher who's only job is to create problems to justify their job by making up arbitrary standards based upon no or flawed data. If other providers can read my note and know why the patient was here and what we did, then I'm happy.

Frankly, most of the notes I read from the primary care setting don't come close to accomplishing that mission. Maybe it's because they're so concerned with HEDIS that they don't have time to actually document why the patient was in their office. I'd say about 20-40% of the notes I read are 3 stanzas of nothing with no history and a normal, click-button exam followed by an A/P that says "sinusitis" with no explanation and a referral. The consult reads "patient with sinusitis." If that's meeting military standards, then our EMR has utterly failed. On the outside, a lot of guys try to make up for bad note writing by sending dictated letters which are often very informative, but that's not an issue due to our resources in the military (no dictation, no transcription).

Admittedly, due to my specialty I don't get tagged with many HEDIS measures, so maybe its harder on the front lines.
 
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Zenman1

Zenman1

5+ Year Member
Oct 31, 2013
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There is a lot of nonsense that the military requires you to include in your note that you probably will not be asking and really don't need to know to do your job well...and don't get me started on HEDIS measures and the crazy idea that sometimes clinical judgement is more important then a measure. Recently, I met with a program director who asked, "how are you able to ask all these questions and document it in a 20-30 min EST?" My response: "I don't and I don't care."

I have a good word template that I created the end of residency and modify at each command to meet their peer review standards. One thing you may want to look at is your hospital attending's peer review sheet to help with this. Personally, I think the only thing that is really important is that a future provider can clearly read your note and figure out what you did any why. The more info in a note, the harder it is to read and get that information. Often the content is not important. For instance, if you find yourself writing out a lot of the he-said-she-said drama in detail, consider just simply saying, "Patient reported anxiety symptoms secondary to partner relationship problems" as opposed to giving the specifics of the drama (although it would be helpful to define the anxiety symptoms). All notes obviously need some comment as to why you don't think the patient is going to kill himself or someone else--not that you can really predict this...

One thing that has really sped up my note writing days has been to keep it short and to actually type during encounters. If you can do this while making good eye contact and showing empathy at appropriate times, give it a type. I've asked patients if it bothers them and most say no or actually like that I am getting their concerns in the record in the moment so it is accurate.

On another note, I am currently looking at civilian jobs and between this and getting records from outside providers it is AMAZING how much shorter most of their notes are compared to ours. Some are paper and you simply check the system or fill in the blank with pen. Others are just a few sentences, but get the point across. Others have no info and suck, but if you have too much info in a literary work of art it also doesn't really help much either. If you want me to send you the template i use i can email it. May not be any better then yours.
Yes, I'd like to look at it. Unfortunately, I'm old school and a two-finger typer so I jot down notes and then do the note later. I do order meds, consults etc, while they are in the room.
 

HooahDOc

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Technology makes it easier. But yeah still sucks.

Anyone else know of the chaperone policy? I forget the actual name, but you must confer with a colleague about the medical necessity of seeing a minor without a parent or chaperone.
 

backrow

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Technology makes it easier. But yeah still sucks.

Anyone else know of the chaperone policy? I forget the actual name, but you must confer with a colleague about the medical necessity of seeing a minor without a parent or chaperone.
Are you talking about in psych? Because in my world the answer is easy: unless it's an emergency a minor without a person with medical decision making powers (not just a chaperone) doesn't get past my front desk. Examining/treating a child without proper consent (over 18) could be assault.
 

HooahDOc

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Are you talking about in psych? Because in my world the answer is easy: unless it's an emergency a minor without a person with medical decision making powers (not just a chaperone) doesn't get past my front desk. Examining/treating a child without proper consent (over 18) could be assault.
Yes, this is for psych. Parents always sign a consent to evaluate and treat, but it's a MEDCOME policy that is causing a lot of irritation. It's rare that you do not have a reason to see a minor individually in psych, and many times things come up in the middle of a session that require the parent leaving the room. Am I supposed to stop and go confer with a colleague before I do this? It's a silly policy.
 

backrow

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Yes, this is for psych. Parents always sign a consent to evaluate and treat, but it's a MEDCOME policy that is causing a lot of irritation. It's rare that you do not have a reason to see a minor individually in psych, and many times things come up in the middle of a session that require the parent leaving the room. Am I supposed to stop and go confer with a colleague before I do this? It's a silly policy.
Yeah, that makes a whole lot of sense for sure..... Wonder what the ICD10 code is for "hit head on wall due to policy, subsequent event"
 
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Chonal Atresia

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Came in to work on Sunday and met five other providers trying to catch up on notes. Monday morning AHLTA goes down immediately prior to seeing my 1st patient and stays down for all eleven patients, finally coming back online right at 1630, which was exactly the time I walked away from my desk and went home.

I have one question. What is the shortest, most concise, intake and follow-up note that can be made, and that satisfies every frick'n person, agency, or government entity that has a hand in this field? I already use a Word document template but am open to any suggestions.
11 patients for the entire day? Is this typical for psychiatry in the military? I know I am in a completely different specialty but routinely see 45-50 patients/day while doing procedures (biopsies, FNAs, nasopharyngoscopes, etc) on most patients. I think my psych colleagues see around 30.
 

Chonal Atresia

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[QUOTE="Chonal Atresia, post: 17007592, member: 220337
 

HooahDOc

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To close the loop, the policy I referred to is MEDCOM Policy Memorandum 15-043. I actually haven't looked at it yet and am about to.
 
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Zenman1

Zenman1

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Oct 31, 2013
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11 patients for the entire day? Is this typical for psychiatry in the military? I know I am in a completely different specialty but routinely see 45-50 patients/day while doing procedures (biopsies, FNAs, nasopharyngoscopes, etc) on most patients. I think my psych colleagues see around 30.
Yesterday I had 11 patients scheduled. Usually it's 11-12. 30 minutes for follow-ups and 1 hour for initial intakes. Three people were no-shows, including 1 intake. I still left with 4 notes to complete. The problem is the admin burden such as profiles, Form 3822's, reviewing notes prior to an intake etc.. Then I get an email from command saying if your name is on the AtHOC list to update your info. Well my name was on the list but I responded with, "I don't know why my name is on this list as I receive the weather alerts/warnings all the time. However, when I click on AtHOC just to make sure my info is correct I get this: 'There is a problem with this website's security certificate.' AHLTA has already gone down multiple times this morning and people ask me why I'm grouchy! Who's in charge of this Army? I drive a Jeep anyway and don't care what the weather is like." Inefficiency is the word of the day, unfortunately everyday in the military. We also found out yesterday not to hold our breath about getting another NCOIC for this clinic. Hope I don't have to buy my own printer paper soon!
 
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HooahDOc

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Jun 23, 2003
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Yesterday I had 11 patients scheduled. Usually it's 11-12. 30 minutes for follow-ups and 1 hour for initial intakes. Three people were no-shows, including 1 intake. I still left with 4 notes to complete. The problem is the admin burden such as profiles, Form 3822's, reviewing notes prior to an intake etc.. Then I get an email from command saying if your name is on the AtHOC list to update your info. Well my name was on the list but I responded with, "I don't know why my name is on this list as I receive the weather alerts/warnings all the time. However, when I click on AtHOC just to make sure my info is correct I get this: 'There is a problem with this website's security certificate.' AHLTA has already gone down multiple times this morning and people ask me why I'm grouchy! Who's in charge of this Army? I drive a Jeep anyway and don't care what the weather is like." Inefficiency is the word of the day, unfortunately everyday in the military. We also found out yesterday not to hold our breath about getting another NCOIC for this clinic. Hope I don't have to buy my own printer paper soon!
At least you get no shows.

I was about to submit a request for leave, but apparently my car has to be inspected by .... I don't know who ... in order to be approved. It doesn't matter that it's a 2016 model year. ugh
 

Chonal Atresia

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At least you get no shows.

I was about to submit a request for leave, but apparently my car has to be inspected by .... I don't know who ... in order to be approved. It doesn't matter that it's a 2016 model year. ugh
I completely forgot about the vehicle inspection before leave thing. It may be a minor nuisance to some people, but to me it seems like a complete slap in the face to a board-certified physician.

Another example of how big brother military has absolute control over your life after you sign the dotted line. If you value any degree of independence and autonomy, do not join.