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Efficient Medical History Documentation Guide

Learn effective techniques for documenting patient history, including medication reconciliation, chief complaints, and HPI recording. Discover tips for setting agendas, entering PFSH data, and handling social history details. Enhance note-taking skills and streamline the documentation process.

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Efficient Medical History Documentation Guide

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  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

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