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Topic starter
We have a bit of a problem (actually, its a huge problem). We have just discovered that if a provider sees a patient and adds a very descriptive PMH and puts the document on hold and the patient goes to see another physician in our clinic, the PMH does not pull into the new office visit. Also, when the 2nd provider signs off the office visit, the 1st provider with the on hold visit and descriptive PMH, sort of loses that PMH. Basically, once he signs his visit, the history will never pull forward. The first signed visit overrides it. I am not sure if this is a system issue, form issue or what, but I tested it with the CCC forms and same thing.... Anyone else notice this and what are the options here? We have many patients who may see several providers on the same day? Why are the clinical list changes not carrying forward when they are signed???
Malissa
Posted : April 17, 2013 1:07 am
PMH is an obsterm and it is not finalized and saved onto the flowsheet until the full document is signed. That is why it is not pulling forward.
Problems/Meds/Allergies/Directives are clinical list changes and can be pulled forward into another visit once signed but the document does not have to be signed.
It is how GE setup the database.
Posted : April 17, 2013 6:59 am
Topic starter
That is what I found out when GE called. We are a multi specialty clinic so it is not unusual for patients to see multiple providers in the same day, so there is lots of information that is getting lost in translation.... We just didn't realize it until now. I really feel that this is a huge flaw in the system.
Posted : April 17, 2013 9:10 pm
You can also have your providers sign the Clinical List Changes when putting the document on hold. That will help your situation.
David Shower
OU Tulsa School of Community Medicine
Posted : April 17, 2013 11:09 pm
It sounds like they are doing that, but they are wanting the obsterms to pull into a new note without the first one being signed off first.
Is that correct Malissa?
Posted : April 17, 2013 11:37 pm
Topic starter
Correct, they are signing the clinical list changes, but they want the obs of PMH to pull into next note. For example, one provider entered an extensive history of a DVT. They didn't sign the note off and the patient left that office and went directly to the surgeon's office. The surgeon did not see the PMH of the DVT and the patient did not mention it because they just told the other doctor. When the first provider signed the note later that day, the surgeon already had signed their note earlier. The DVT history never made the PMH and the patient assumed it was already there. So, it's not like it's a case of providers waiting days or weeks to sign off on notes, it could be as little as a few hours…..
Posted : April 17, 2013 11:43 pm
Do the multiple visits take place at the same facility? We have audiologists and surgeons in the same facility and they share the office visit encounter if a patient sees both specialities in the same day. We only separate encounters if they take place in different facilities/locations from each other.
Posted : April 17, 2013 11:46 pm
Topic starter
Same facility, different locations of care. We have approximately 20-25 locations of care in order to make our billing work correctly and so that the appointment reminders show patients who their appointments are with.
Posted : April 17, 2013 11:49 pm
