Chart Prep Guide
There are many different ways you can review charts in order to be prepared for the patient’s visit. Talking with your senior residents to get an idea of how they do it can be useful.
Reasons for chart prep include:
Familiarizing yourself with the patient’s overall health, including tobacco, alcohol, or other substance use, support system (family, etc.), employment status
Identifying preventive care needs
Identifying any medications that need to be refilled
Identifying any labs for which a patient is due, either as part of preventive care or lab monitoring
Reviewing the past few visit notes and identifying any interim follow up that should have occurred with our clinic or with a specialist. If it did not occur, you’ll want to ask the patient what the barriers were.
Reviewing results of any testing done since the last visit at our clinic
Reviewing results of any visits and testing done elsewhere since our last visit with the patient (ED, etc.)
It is possible to do some actual pre-charting (like place orders and pull up a skeletonized note) before your patient arrives, but you should be aware that if they no-show, your note will be lost (the orders will not be lost, however). You can also plan ahead in a manner that won’t be lost by using the “sticky notes” on the top left of your screen when you open a chart. When you use the yellow sticky note, only you will see the contents. When you use the blue sticky note, anyone else in family medicine will be able to see the contents.
An example flow for chart prep is:
Open yellow sticky note – Make notes to yourself there of anything you want to discuss in the visit
Check WIR (Wisconsin Immunization Registry) and make a note to yourself in the yellow sticky note of vaccines due.
Health maintenance – review the Health Maintenance tab and make note of anything that is due after verifying this is really the case. Sometimes vaccines are in WIR but our HM tab does not reflect that or a pap is listed as due but really it is not. Ask your seniors or staffers how to use the “edit modifiers” and “document past immunization” tabs in the HM tab.
Problem List – review this. Is there anything that needs cleaning up in the list? Sometimes something will be in there from several years ago that is no longer accurate or relevant. Does something catch your eye that might need follow up like “pulmonary nodule” about which you’ll want to do some chart digging to see if a repeat CT is due, etc.?
Medications – are they on medications that need periodic monitoring? You can check this by going to “chart review” and then the “labs’ tab.
Chart Review – here you can review medications, notes, relevant imaging studies, and procedures.
You can use sticky note to jot down notes about all of these things as well as items you want to follow up on like “tolerating statin?” if you started a statin at the last visit or “taking the fluoxetine?” if you’re wondering if the patient followed through on a medication change.
OB patients-they’ll have a pink sticky note which everyone can see. That’s a great place to put things like “Does not want to know the sex” or “Rh negative” or the partner’s name.
These dot phrases may be useful to you when you are writing your clinic visit notes:
.aimsoap You can “steal” this from Ildi Martonffy’s dot phrases. This is a “SOAP” note but in “APSO” format. You don’t need to use this, but it is color coded in a way that makes it easy to look back on your last visit when you next see the patient.
.patin This will blow in the patient instructions you entered in the “instructions” area. You can quickly get to the patient instructions when you are charting by typing “ctrl + shift” + “i.”
.diag This will blow in all of your visit diagnoses. In order for this to be most useful, you will want to associate all relevant orders and medications ordered during the visit with the appropriate diagnosis. That way if you type in .diag and have coded for HTN, for example, you’ll enter “Essential hypertension; Lisinopril 10mg, BMP, Microalbumin” all by just typing .diag
Instructions “ctrl + shift” + “i.”
Smart Set “ctrl + shift” + “s.”
Orders “ctrl + shift” + “o.”
Routing “ctrl + shift” + “r.”
Things to ask a senior resident of faculty member to show you:
How to assign a “priority” to items on the problem list – this puts higher priority items at the top of the list because you might want your attention drawn to their CAD and CHF first rather than their astigmatism.
How to “filter” notes or labs to pull up, for example, only Fam Med visit notes or only Cardiology visit notes
How to review historical meds
How to use the “Google search” function in a chart. In brief, this is in the upper right corner once you are in a patient’s chart. You can search any word and it will pull up occurrences of this word in the chart.