It’s been said before that a good story has five elements: the characters, setting, plot, conflict, and resolution. That last element, the resolution, is key to concluding the story. It’s so important that a story without a resolution can often produce confusion or anger in the audience (think series finale of The Sopranos).
Similarly, a medical record should tell a story to anyone who reads it. It should tell the reader why the patient was being seen (the Reason for Visit), the patient’s backstory (the Case History), their present state (the Physical Exam), what you as the doctor feel the history and physical exam suggest (the Assessment) and what you plan to do about it (the Plan). If any of those parts are missing, the logical flow of information from start to finish is lost. And perhaps most importantly, a medical record without a plan at the end provides opportunity for a 3rd party to reviewer to argue that the exam was of no benefit to the patient. After all, the patient was there for a specific reason, yet the doctor didn’t summarize how the visit influenced care.
For that reason, it’s critical that each encounter you provide concludes with a clear plan of care where you summarize your thoughts and plans for the patient. That’s not only good for compliance but also continuity of care.
There are a number of methods to efficiently document your care plans in RevolutionEHR. The video below provides a walk-through of those methods.