Information Governance & Standards

H&P requirements for structured notes and meaningful use

  • 1.  H&P requirements for structured notes and meaningful use

    Posted 14 days ago

    Good afternoon,

    I was hoping to gain some feedback on what your organizations polices are about non-dictated H&Ps, or if you can share some examples of what your EMR structured H&P looks like/consists of, and if you are having any struggles with physicians getting them completed on time. About a year ago, we brought on a self-editing dictation system (M*Modal) so the physicians can dictate directly into our EMR(Allscripts) instead of using transcription. One of the biggest struggles that we have had so far is with the H&P document and how time consuming it is to fill out in the EMR. Currently our H&P document is full of radio buttons, drop downs, and just small text boxes where physicians can dictate some of the story. Our informatics team has not been able to support much change to this document due to the information that is in those radio buttons is connected to meaningful use and is information that is pulled in throughout the rest of the chart onto other documents. If the physician was the one creating the document they would reduce almost all of those radio buttons and just have a large space to dictate like they would when sending to transcription. At this time I feel that we are in a bit of a tug of war over supporting the continued reduced costs of transcription in support of the self-editing, supporting the physicians concerns about the time it is taking them to get their notes done, and the push for meaningful use. Any help or ideas that you have would be greatly appreciated.



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    Sandra Furlow
    United Regional Health Care System
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  • 2.  RE: H&P requirements for structured notes and meaningful use

    Posted 11 days ago

    We  have an H & P template in our EMR for free text (no drop downs, etc.).  They can either type directly in the template, dictate the "old-fashioned way", or use Speech Recognition.  (We have limited licenses for Speech Recognition).   I would say we have 50% dictate and 50% type the H & P themselves.

     

    We have a group of physicians that we have to report MIPS Indicators for and our IS Department set up "Assessments" in our EMR that can be reported/transmitted to our Qualified Registry.  We have Meditech.

     






  • 3.  RE: H&P requirements for structured notes and meaningful use

    Posted 9 days ago
    ​You are not alone.  We too struggle with the same thing. I am on Informatics, but I am the lone person interested and getting the quality back into those reports and reducing the amount of " hard" coded data in these documents. If we come up with any great ideas, I will post them.

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    Stacey Goodenough
    Manager of Medical Records / Privacy Officer
    Wayne Memorial Hospital
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