Third parties have certain expectations when it comes to medical records. One of the fundamental expectations is that each encounter should start with a clearly stated reason (or reasons) for why the patient is being seen. This reason can originate from the patient (e.g. My right eye is red and I want to make sure it’s OK.), or it can be physician-directed (e.g. Patient returning for 4-month IOP evaluation for glaucoma as directed.). In either case, the documentation should be to a degree of clarity and specificity that anyone reviewing the record, doctor or otherwise, is capable of following the delivery of care.
In the case of physician-directed visits (i.e. those visits where you have told the patient to come back in a certain period of time for continued care), your efficiency and documentation can be enhanced through the use of the Dx/CPI Reason for Visit component on the RFV screen.
Step 1: Select the Lookup tool to the far right of the Dx/CPI RFV component. See Example
Step 2: Work within the Clinician RFV Selector window to choose the care plans driving the current encounter. See Example
- You will then see the selected care plans appear in the Dx/CPI Reason for Visit component. See Example
Not only does that provide an efficient way to document the doctor’s reason for this visit without typing, but it also connects this encounter to the plan of a previous encounter for irrefutable proof of the doctor’s order.
The video below offers an illustration of the above ideas.