Third parties have certain expectations when it comes to medical records and one of the fundamental ones 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 (i.e. “My right eye is red and I want to make sure it’s OK”) or it can be physician-directed (“Patient returning for 4-month IOP evaluation for glaucoma as directed”). But 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 (those visits where you’ve 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:
Step 2: Work within the Clinician RFV Selector window to choose the care plans driving the current encounter:
You’ll then see the selected care plans appear in the Dx/CPI Reason for Visit component:
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 one for irrefutable proof of the doctor’s order.
The video below offers an illustration of the above ideas.