Your HPI: it should be longer than a tweet

The history of the present illness should be longer than a tweet and twice as informative. 

Any twitter users out there? If so, you know that 140 is the maximum number of characters, including punctuation and spacing.

Why bring this up in the context of electronic health records?  Because too often, the HPI in EMR notes is shorter than a tweet.  And less informative.  The history of the present illness describes the reason for the visit and the patient complaints related to the reason.  How about this run on sentence?

The patient presents with a red rash on her forearms that has steadily worsened for three days despite application of calamine lotion and she wonders if while she was gardening she got into poison ivy because she noticed it upon awakening after pulling weeds and it is very itchy.

That sentence is precisely 280 characters, or about twice as long as a tweet.  And here it is with the elements added into the sentence.

The patient presents with a red (quality) rash on her forearms (location) that has steadily worsened (severity) for three days (duration) despite application of calamine lotion  (modifying factor) and she wonders if while she was gardening (context) she got into poison ivy because she noticed it upon awakening (timing) after pulling weeds and it is very itchy (associated sign and symptom).

Our fourth grade English teachers would have encouraged us to break that sentence up into smaller bits, but it does give a clear, concise description of the reason for the visit.  When physicians dictate their notes, the reason for the visit and the symptoms and complaints are usually well documented.  But, when a clinicians switches to an EMR program, documenting the HPI becomes problematic.  Sometimes, the clinician types the HPI into the record.   Who does this make sense to, can I see a show of hands? Take the person with the highest education in the building and ask her to do some typing for you.  Or, a provider can use voice recognition software and “dictate” their HPI and clinical comments in the assessment.  Sometimes, this is time saving.  Sometimes, this results in documentation with clearly recognizable voice recognition errors.  Or, the physician might click, click, click on a template and the output will be single words in the each HPI category or a sentence that may or may not make sense.

It is even more difficult to document the status of a patient’s chronic illnesses in an EMR.  Either the clinician has to type or dictate, or use a template that results in notes that look exactly the same for all patients.  “The patient has received a handout that describes a diabetic diet.”

The problem is, the HPI is one of the most important parts of a medical note for that physician who sees the patient at a later date or for a covering physician.   Failing to document it in sufficient detail, copying it word for word from a previous visit or using single words instead of complete sentences: none of those are helpful.  And, HPIs that are shorter than tweets and half as informative are useless.

 

 

 

 

Transitional Care Management (TCM) update

Date of service: use 29th day following discharge or counting day of discharge as day one, day 30.

Place of service: use place where mandated, bundled face-to-face E/M occurred.

What does licensed clinical staff mean?  No clarification yet from CMS.  FAQ being developed by them.  All staff must practice within their state scope of practice.

If patient is re-admitted during 30 day period, may still bill TCM 30 days after first discharge date if TCM services provided during the period.   May not report to TCM services, one for each discharge/TCM period.