Charting / Note-taking

[Guest guest]

Hi All;

I have a question regarding the detail taken during charting by the list.

How much of the encounter do you record?

How much of the appointment is spent writing?

How important do you feel charting is?

What is the most important part?

 

 

Thanks for any answers,

 

Hugo

 

 

________

Sent from Mail.

A Smarter Email http://uk.docs./nowyoucan.html

 

 

[Guest guest]

HI Hugo,

 

My answers to your questions is that everything is variable.

 

If someone comes in with an injury, I ask fewer questions about general health,

and focus extensively on the injury. I write down what I think I will need to

know for future visits, and I write down any ratings the patient gives me, so I

can compare results of treatments with previous symptoms. I also write down,

for every visit, exactly what I do - in detail, even including needle gauge.

 

For someone with more internal issues, I do a very extensive health review,

asking and writing down everything under the sun. Patients comment on how no

one had ever considered the interrelationships of all their varied health issues

before coming to see me, and feel " heard " , often for the first time in their

lives. I personally find this valuable when I am considering herb formulas,

which I often research after the first visit, on my own time. I find it

extremely useful to be able to have all the necessary information right in front

of me.

 

I also keep such detailed records, should I ever have to appear in court on

behalf of a patient.

 

Sometimes I am impatient with my own obsessiveness about attention to such

minute details, and the time they do take, but somewhere down the line, I

usually find a reason to be grateful for having this discipline. I frequently

find solutions for my patients hidden in the myriad details about the condition

of their health. What I know from experience, however, is that being an

excellent diagnostician makes me a better healer than I otherwise could be, and

keeping track of the details is part of the process. You might call it a

" necessary evil " .

 

So, specific answers to your questions:

 

How much of the encounter do you record?

Everything. I make special effort to record any emotional reactions to

treatment, benefits, and adverse reactions.

 

How much of the appointment is spent writing?

I spend more time talking and less time writing, except on the first visit, when

much time is spent writing as the patient describes their concern, and answers

my questions. This can be as much as 45-60 minutes writing and talking on the

initial visit, and as little as 5-10 minutes on subsequent visits. Really, it

depends on the complexity of the case, with more complicated concerns taking

more time.

 

How important do you feel charting is?

While charting does not directly benefit my patients, I consider it of utmost

importance for reasons mentioned above.

 

What is the most important part?

On the first visit, all of the 10 questions (for patients with internal health

issues). On subsequent visits, information about progress and any adverse

reactions. I also pay attention to frequency of treatment, and how this impacts

or impedes their progress. Also - on follow-ups, I am careful to write down

anything the patient does that is contrary to my recommendations (diet, taking a

break from rigorous exercise, not resting enough, etc.), that could delay

progress, or cause relapse of symptoms/illness. I do this because patients have

notoriously short memories once their symptoms start to abate, and are quick to

resume activities and lifestyles that originally brought them to seek my help -

by keeping this info in their charts, I have in handy to show them proof of what

helps, and what hurts.

 

 

 

Hugo Ramiro <subincor wrote: Hi All;

I have a question regarding the detail taken during charting by the list.

How much of the encounter do you record?

How much of the appointment is spent writing?

How important do you feel charting is?

What is the most important part?

 

 

Thanks for any answers,

 

Hugo

 

 

________

Sent from Mail.

A Smarter Email http://uk.docs./nowyoucan.html

 

 

[Guest guest]

Dear Hugo,

You have posed some very basic - and very broad - questions about

charting. I have addressed the topic of recording care extensively in

my text, Quality in Complementary & Alternative Medicine. See Chapters

12.1, 12.2, and 7.2.

 

You might also consult the medical records standards of the American

Health Information Management Association (AHIMA). Note that you must

deal not only with chart note contents, but with the management of

medical records (e.g. definition of designated record set, medical

record, and legal medical record; authorized abbreviations; authorized

entries; etc.) and conditions for their release.

 

After you've read this material, then try to arrange to read some

first rate medical records. Good chart notes are written in a

formalized style, tersely factual in description, cautionary in

conclusion, and conveying only the essentials. These stylistic

conventions do not preclude the inclusion of key portions of the

patient's story that contribute to your understanding of the patient

and his or her condition.

 

Best regards,

 

David Kailin, Ph.D., M.P.H., L.Ac.

http://www.convergentmedical.com

[Guest guest]

Dear David, interestingly, I put your book on order a couple of weeks ago.

I am sure you elaborate on this in your text, but let me put it out there

anyway: what are the detractions to a formalised style of writing?

 

Thanks,

Hugo

 

 

 

convergentmedical <kailin

Chinese Medicine

Thursday, 5 June, 2008 2:34:49 PM

Re: Charting / Note-taking

 

 

Dear Hugo,

You have posed some very basic - and very broad - questions about

charting. I have addressed the topic of recording care extensively in

my text, Quality in Complementary & Alternative Medicine. See Chapters

12.1, 12.2, and 7.2.

 

You might also consult the medical records standards of the American

Health Information Management Association (AHIMA). Note that you must

deal not only with chart note contents, but with the management of

medical records (e.g. definition of designated record set, medical

record, and legal medical record; authorized abbreviations; authorized

entries; etc.) and conditions for their release.

 

After you've read this material, then try to arrange to read some

first rate medical records. Good chart notes are written in a

formalized style, tersely factual in description, cautionary in

conclusion, and conveying only the essentials. These stylistic

conventions do not preclude the inclusion of key portions of the

patient's story that contribute to your understanding of the patient

and his or her condition.

 

Best regards,

 

David Kailin, Ph.D., M.P.H., L.Ac.

http://www.converge ntmedical. com

 

 

 

 

________

Sent from Mail.

A Smarter Email http://uk.docs./nowyoucan.html

 

 

[Guest guest]

Dear Hugo,

On the positive side, the formalized style of writing chart notes

augments rapid comprehension. The writer conveys condensed reports of

conditions, lines of reasoning, taken and intended actions, and

conversations. Rapid comprehension is supported by the organization of

the material (e.g. SOAP notes format). Chart notes are augmented by

summary lists (e.g. problem list, medication list, allergies).

 

On the negative side, the terse matter-of-factness of the formalized

style does not invite the recording of vivid details of the patient's

narrative of an illness experience. The templates of electronic

medical records may be similarly uninviting. Conveyance of the

patient's illness experience is further eroded by the time pressures

experienced by clinicians.

 

Excellent charting manages to convey the essentials without eclipsing

the patient's lived situation and illness experience.

 

Best regards,

 

David Kailin, Ph.D., M.P.H., L.Ac.

http://www.convergentmedical.com

 

 

 

Chinese Medicine , Hugo Ramiro

<subincor wrote:

>

> Dear David, interestingly, I put your book on order a couple of

weeks ago.

> I am sure you elaborate on this in your text, but let me put it out

there anyway: what are the detractions to a formalised style of writing?

>

> Thanks,

> Hugo

[Guest guest]

Dear David,

I am writing because I am slowly digesting your book, and wanted to thank you

for the immense effort that went into it. I appreciate your work.

 

Thanks again,

 

Hugo

 

 

 

________________________________

Hugo Ramiro

http://middlemedicine.wordpress.com

http://www.chinesemedicaltherapies.org

 

 

 

 

 

convergentmedical <kailin

Chinese Medicine

Saturday, 7 June, 2008 12:33:36

Re: Charting / Note-taking

 

 

Dear Hugo,

On the positive side, the formalized style of writing chart notes

augments rapid comprehension. The writer conveys condensed reports of

conditions, lines of reasoning, taken and intended actions, and

conversations. Rapid comprehension is supported by the organization of

the material (e.g. SOAP notes format). Chart notes are augmented by

summary lists (e.g. problem list, medication list, allergies).

 

On the negative side, the terse matter-of-factness of the formalized

style does not invite the recording of vivid details of the patient's

narrative of an illness experience. The templates of electronic

medical records may be similarly uninviting. Conveyance of the

patient's illness experience is further eroded by the time pressures

experienced by clinicians.

 

Excellent charting manages to convey the essentials without eclipsing

the patient's lived situation and illness experience.

 

Best regards,

 

David Kailin, Ph.D., M.P.H., L.Ac.

http://www.converge ntmedical. com

 

Traditional_ Chinese_Medicine , Hugo Ramiro

<subincor@.. .> wrote:

>

> Dear David, interestingly, I put your book on order a couple of

weeks ago.

> I am sure you elaborate on this in your text, but let me put it out

there anyway: what are the detractions to a formalised style of writing?

>

> Thanks,

> Hugo

 

 

 

Send instant messages to your online friends http://uk.messenger.