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

1. 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

2. Getting the History Right • Before you enter the exam room • Office Medication Reconciliation • Importance of Chief Complaints • Recording HPIs in the Exam Room • Past, 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

3. “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 provider • Vitals • Chief Complaints • Start with Reason for return (from last visit) • Reason for visit as entered by scheduler • Add new complaints voiced by patient

4. Setting the agenda • Before 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

5. Recording HPIs in exam room • Sit with tablet & patient arranged in “therapeutic triangle” • Take histories in order of priorities • Enter 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

6. Why, when, & how to enter PFSH into structured modules • Documentation 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:

7. Medical History • This 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 • 6/15/2007 – T3, N2, M1 – Estrogen receptor negative, • 8/25/2007 – Completed radiation therapy • 12/16/2007 – Completed combination chemotherapy …

8. Allergies/Intolerance • This powers the drug/allergy checker • Whenever possible, entries should be structured • Treatment of allergic conditions should be progress notes and Problem List

9. Gyn & Ob Histories • Expect changes as Ob-Gyn content upgraded! • Currently muddle together Gyn and Preventive • Ob history currently free text

10. Surgical History • Browse feature could help with appearance, but . . . • Like Medical History, list of free text fields • Date field can be very helpful

11. Hospitalizations • Browse feature could help with appearance, but . . . • Like Medical History, list of free text fields • Date field can be very helpful

12. What should go where? • Hospitalizations • Past sentinel admissions, e.g. psychiatric admission following suicide attempt • All hospitalizations on-going • Surgical 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.

13. Family History • Documentation in note need only pertain to today’s visit • Something needs to be documented in this module for Preventive Services, but level is at discretion of PCG

14. Social History • Documentation 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.”

15. Review of Systems • In 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