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 section on the RFV screen.
- Click 'Add' within the Dx/CPI Reason for Visit section. See Example
- Within the Past Diagnosis and Care Plans modal, click on a Past Diagnosis. The Past Care Plan Items section displays the associated care plan(s). See Example
- Click the checkbox(es) for the appropriate care plans.
- Click 'Save.' The associated diagnosis to the selected care plans display on the RFV screen of the encounter.
- If multiple diagnoses are added, a checkbox is available to indicate the primary reason for visit. 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.