History – Putting Enough In, Leaving the Right Stuff Out, Making it Legible, &

Getting Done!The Hardest Element to Document Effectively- Making it Relatively Easy!Bryan L. Goddard, M.D.August 2010

Getting the History RightBefore you enter the exam room

Office Medication Reconciliation Importance of Chief Complaints

Recording HPIs in the Exam RoomPast, Family, & Social History – Different Standards

for the Chart and the Note!Review of Systems – Why we won’t “go there” until

we cover Preventive Services

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“Rooming” is more than “hostess-ing”Staff can set you up for success!Office medication reconciliation

Carry forward current medications? If errors, verbal communication from nurse to

providerVitalsChief Complaints

Start with Reason for return (from last visit) Reason for visit as entered by scheduler Add new complaints voiced by patient

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Setting the agendaBefore entering room, add “provider chief complaints”:

From previous visit note From review of vitals From review of recent labs/DI From “sticky notes” From review of problem list & encounters list Set up HPIs – don’t put too much in them!

After ice breakers, List chief complaints, and who brought them up Ask for any not on list Prioritize work for today’s visit

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Recording HPIs in exam roomSit with tablet & patient arranged in “therapeutic

triangle”Take histories in order of prioritiesEnter data while patient talking – helps you not

interrupt, patients will reveal most of HPI before you need to ask clarifying questions

Before moving to next HPI, if visit feels like 99214, make sure you are building to 4 HPI points, PFSH, and 2 ROS

Help patient analyze problems by completing each HPI before moving on

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Why, when, & how to enter PFSH into structured modulesDocumentation standards for reimbursement only

pertain to the content of today’s note.“History verified” adds every piece of information

from structure module to today’s encounter!Legally, primary care providers are supposed to

gather & maintain PFSH by at least the third visit.Documenting PFSH is a requirement of Preventive

Service visits, but even a check mark will suffice if content is stored in separate location of record

Specific recommendations follow:

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Medical HistoryThis is simply a list of free text fields Browse feature helps make it easier to work with, e.g.

Colonoscopy – Add date of last & findings Add repeat dates on same line Enables us to do search

This can be great place to “inform” the Problem List Problem List has 174.4 Breast CA Upper Outer Quadrant Medical History has

o 6/15/2007 – T3, N2, M1 – Estrogen receptor negative,o 8/25/2007 – Completed radiation therapyo 12/16/2007 – Completed combination chemotherapy …

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Allergies/Intolerance This powers the drug/allergy checkerWhenever possible, entries should be structuredTreatment of allergic conditions should be progress

notes and Problem List

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Gyn & Ob HistoriesExpect changes as Ob-Gyn content upgraded!Currently muddle together Gyn and Preventive Ob history currently free text

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Surgical HistoryBrowse feature could help with appearance, but . . . Like Medical History, list of free text fieldsDate field can be very helpful

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HospitalizationsBrowse feature could help with appearance, but . . . Like Medical History, list of free text fieldsDate field can be very helpful

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What should go where?Hospitalizations

Past sentinel admissions, e.g. psychiatric admission following suicide attempt

All hospitalizations on-goingSurgical History

Major one-time cases Omit “trivial” procedures done in conjunction with

hospitalizations, e.g. chest tube following CABG

Medical History Recurring procedures, e.g. colonoscopies Treatment details, including procedures, e.g. breast CA –

lumpectomy with axillary dissection, etc.

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Family HistoryDocumentation in note need only pertain to today’s

visitSomething needs to be documented in this module

for Preventive Services, but level is at discretion of PCG

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Social HistoryDocumentation in today’s note is “security through

obscurity,” i.e. sensitive details when recorded become hard to find after many visits, however . . .

Document sensitive details only to a level needed for others to render care appropriately, e.g. “past alcohol abuse, last drink 2000” instead of “DUI, restraining order from first wife, & lost job

before going into rehab 10 years ago.”

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Review of SystemsIn general, you should be able to easily record this

as part of HPI without going to this section of note – except for: 99204 – New Patient, Moderate Complexity 99205 – New Patient, High Complexity 99215 – Established Patient, High Complexity 99244 – Office Consultation, Moderate Complexity 99245 – Office Consultation, High Complexity Preventive Services

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