The heart of any patient record is the progress notes. ComChart's progress note file was designed to give the physician easy access to everything that may be required during a typical patient encounter; including the patient's problem list, medicine list, flow sheets, prescriptions writing, lab results, radiology results, patient scheduling, ordering tests as well as the ability to see if the patient has a future appointment scheduled.
Navigation from one progress note to the next is accomplished by clicking on the arrows in the bottom right of the screen. Alternatively, one can "jump" directly to a particular progress note by click on the progress note's date (which are listed in the bottom left of the screen.)
If one wants to view the patient's lab results, radiology results, create an encounter form, or order diagnostic tests, they need only click on the blue navigation buttons located in the bottom left or the black and yellow "ComChart" button located in the upper left corner.
Progress Note File
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User specific, pre-written comprehensive progress notes (or composite progress notes) can be added to the patient's progress note by clicking on the "Pre-written PGN" button located at the bottom of the screen. The user is then presented with a list of their own pre-written progress notes. Any of these notes can be added to the patient's chart by clicking on the name of the note. There are 2 methods for creating template progress notes. ComChart™ has a standard history and physical form which will enable you to create a comprehensive initial history and physical without the need for extensive typing. It also includes many template progress notes which can be used to create comprehensive follow-up progress notes, again, without the need for extensive typing. These template notes are user specific. Further, there is no limit to the number of template progress notes a user can create. The user can even string together a series of these template notes to create one large progress note.
There are two types of template notes. The first allows the user to create a full progress note, or sections of a progress note, that can be assembled in pieces, by clicking on the name of the template note, as shown below. The second set of templates allow the user to assemble a customized H & P by clicking on individual items (physical findings, positive and negative ROS) to create a truely customized and comprehensive progress notes.
The user (without knowledge of programming) can easily modify all of these notes and additional notes can be created at the click of a button. Usually, after I import one of the pre-written progress notes into the patient's progress notes, I then proceed to change a few words or add a sentence or two so that the pre-written progress note accurately reflects the patient encounter.
In a similar manner, the health care provider can add comments to the patient's progress notes using the "PGN comment" button. After clicking on the "PGN comment" button, you are presented with the progress notes comments layout.
Progress Notes Comments layout
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Any of the user specific "progress notes comments" can be added to the end of the progess note by clicking on the desired line. Each user creates their own list of frequently used phrase, all of which can be easily edited.
The secretary may have a series of "progress notes comments" around the theme "The patient did not arrive for today's visit" or "The patient cancelled their next appointment" while the nurse will have "progress notes comments" like "The patient has requested a refill of XXXX medicine," "Returned patient call, no answer," and "The patient was informed the tests are normal."
Currently, my "template progress notes comments" button includes the following:
Patient aware of above.I left message to for patient to call me.
TELEPHONE CONVERSATION WITH PATIENT:
OK to refill Rx for XXXX months with YYYY refills.
OK to refill Rx for 1 months with 0 refills.
OK to refill Rx for 2 months with 0 refills.
Tell patient blood test is normal.
Tell patient blood test is normal, continue current Rx.
Tell patient mammogram is normal.
Tell patient Pap smear is normal.
Tell patient stool guaiac is normal.
Tell patient throat culture is normal.
Tell patient the xray is normal.
Tell patient the ultrasound is normal.
Tell patient the urine test is normal.
Tell patient the patient blood and urine tests are normal.
Tell patient blood tests and xrays are normal.
Tell patient the cholesterol is normal.
Tell patient the cholesterol is normal. Continue current Rx.
Tell patient the cholesterol is a little high. Begin a low fat diet.
Tell patient the cholesterol is high. Please arrange for a fasting lipid profile to be done in the near future.
Tell patient the cholesterol is high. I would like them to see the dietician.
---------------------- BLOOD SUGARS ----------------------
Tell patient blood sugars are excellent.
Tell patient blood sugars are excellent, continue current Rx.
Tell patient blood sugars are very good.
Tell patient blood sugars are very good, continue current Rx.
Tell patient blood sugars are good.
Tell patient blood sugars are good, continue current Rx.
Tell patient blood sugars are fair.
Tell patient blood sugars are improving. Continue current Rx.
Tell patient blood sugars are too high. Change to XXX and call me with QID CBS in 1-2 weeks.
Tell patient blood sugars are too high, phone in QID CBS in 1 week.
---------------------- THYROID ----------------------
Tell patient the thyroid hormone level is normal.
Tell patient the thyroid hormone level is normal. Continue Rx.
Tell patient the thyroid hormone level is high.
Tell patient the thyroid hormone level is low.
Tell patient thyroid biopsy. See me as planned.
---------------------- COUMADIN ----------------------
Tell patient coumadin level is good, continue Rx.
Tell patient coumadin level is high. Change to mg and recheck prothrombin time in 4-5 days.
Tell patient coumadin level is low. Change to mg and recheck prothrombin time in 4-5 days.
Tell patient coumadin level is off. Continue current Rx and recheck prothrombin time in 1 week.
---------------------- SEE ME ----------------------
Tell patient to see NP.
Tell patient to see me.
Tell patient to see me or NP.
Tell patient to see me. They require more Rx.
Tell patient to see me to discuss results.
Tell patient to see me within the next month to discuss results.
---------------------- MISCELLANEOUS ----------------------
When is the patient's next appointment?
Please call patient. Are they getting better?
Tell patient I am waiting for more results.
Tell patient I will call them after next test.
Tell patient I have received the results and I am deciding how to proceed.
I will discuss the above test results at the patient's next office visit.
Additional tests pending.
Please locate missing lab results: XXXX
I have found the "template progress notes comments" are a very efficient way to add information to the patient's medical record.
If the user wants to print prescriptions, they should click on the "Rx" button, locate above and to the right of the patient's medicine list. Patient handouts can be printed by clicking on the green button in the bottom/center of the progress notes. Medications and problems can be easily added to the appropriate lists. If the patient has a long list of medical problems (or medications,) which appears in their written progress note but it is not in the patient's Problem list, the user need only highlight the list of problems in the progress note and click on the "+" button. ComChart will then automatically add the highlighted diseases (or medications) to the patient's problem list (or medicine list.) This feature makes it very easy to keep the patient's medicine list and problem list up to date.
Users can store graphics such as scanned EKGs, letters and videos (cardiac cath films) in ComChart as a progress note.
One very important feature of ComChart is the patient's "flow sheet." The flow sheet, which can be accessed via the "flow sheet" button in the bottom left of the screen, stores the dates of the patient's Pap smears, stool guaiac tests, diabetic ophthalmology evaluation, vaccination history and other "routine" screening data. Using the "Is the patient up to date?" button on the patient's flow sheet, the user can immediately determine which diagnostic tests/vaccinations need to be given. As a result of this feature, my office's compliance with the recommended routine health maintenance protocols exceeds both the national and local averages. The patient's flowsheet can easily be modified by the user. The Patient Flow Sheet.
