First and foremost, documentation by a family physician in the medical record is guided by the relevant state medical board regulations and other common codes of professional ethics and responsibility. However, the CMS E&M documentation, coding, and billing rules, and the AMA CPT codes are recognized as being the primary root causes of the existing repression of family medicine, which is why they are not used in the SENTIRE system. SENTIRE just asks that the physician bill a patient based on how thoroughly each issue is addressed, which is supported with brief documentation of the conversation and issues addressed.
ELEMENTS OF INDIVIDUAL PROGRESS NOTES BY ENCOUNTER TYPES
NEW SYMPTOM OR SIMILAR ISSUE
A progress note for a patient who presents with a symptom or similar issue who is new to the treating physician or practice should include the following elements:
- Patient concerns
- History of present illness (HPI)/any additional review of systems
- Examination
- Assessment
- Plan
It is assumed that a primary care physician seeing a continuity patient more than once knows the past historical elements likely recorded on the summary page, and does not need to repeat this information on an individual progress note.
Patient concerns
Patient concerns are not necessarily limited to a discrete symptom. It could be for another reason the patient made the visit – for example, a patient asked to see the physician urgently because of a low potassium value discovered in a recent blood test.
History of Present Illness (HPI)
The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. The history is the most important component of a patient encounter, because 80-90% of the information required to make a diagnosis or guide the first phase of testing is contained in this section. The HPI could include the following elements:
- timing,
- location,
- quality,
- severity,
- duration,
- context ,
- modifying factors,
- associated signs and symptoms,
- presence or absence of similar symptoms in past,
- results of previous tests for similar symptoms,
- and response to previous treatments for similar symptoms.
The most important element of this list is usually the timing of the symptom, both the total time since the symptom started, and the timing of episodes within the total timeframe.
- For example, abdominal pain for three days could mean constant gradually worsening pain that never remits, or five minutes of pain once per day for three days.
- Almost all HPIs should contain explicit information on the timing of the chief complaint.
If the visit is for the follow up care of an acute issue previously documented, then the progression of the original symptoms or other findings since the index visit should be documented.
ROS
The amount of information required for the ROS in a clinical encounter is not specified, but is at the discretion of the physician, guided by medical-legal considerations and the prevailing local standard of care.
Physical Examination
The amount of information required for the examination section is not specified, but is at the discretion of the physician, guided by medical-legal considerations and the prevailing local standard of care.
Assessment
The assessment is the summary of the physician’s findings after obtaining the necessary information from the HPI, physical exam, and available tests. The assessment could be a symptom such as cough or fever, or it could be a final diagnosis such as pneumonia. Occasionally, the issue could be a social issue such as intimate partner violence or marital discord.
Plan
The treatment plan could include numerous approaches such as further testing, over-the-counter treatments, prescriptions, reassurance, or even allowing more time to elapse for a vague or nonspecific symptoms to evolve.
The physician may specify all elements of the assessment in one list and all elements of the plan in a separate list. Or the addressed issues could be listed in assessment-plan pairs.
Notes:
- The results of previous test results may be included in the HPI or a separate lab/X-ray section.
- For patients with more than one new symptom or other issue, only the chief complaint and HPI must be recorded discretely for each issue. One ROS, physical examination, and lab/X-ray section is sufficient.
CHRONIC DISEASES
Long term chronic disease care is often more complex than acute care in many ways. Patients with even one chronic disease may have widely variable life experiences simply because of the severity of the underlying disease. Patients with more than one chronic disease must deal with this reality multiplied by the number of chronic diseases, plus the interactions of multiple medications, test results, and overlapping symptoms. On the other hand, some chronic diseases usually have no symptoms, such as hypertension. Therefore, the documentation priorities of chronic diseases are different from acute illnesses.
A clearly discrete exacerbation of a chronic disease may be documented as a new acute symptom. Some examples:
- a patient with an acute asthma attack who is usually well controlled, or
- a patient with heart failure who’s had worsening orthopnea for two days.
A progress note for assessment of a chronic disease includes the following elements:
- The effect of the disease on the patient’s Quality of Life
- The effect of the disease on the patient’s Functionality
- Each chronic disease’s Medications: Tolerance, Adherence, Reconciliation
- Pertinent Physical Examination
- Pertinent Test Results
- Issues Addressed and Treatment Plan
Each section is further defined below.
Quality of Life
The pertinent details of this section depend on the disease in question. For example, an asthma note should document rescue inhaler use; an osteoarthritis note should document daily and episodic pain levels. The amount of information required for this section is not further specified, but is at the discretion of the physician, guided by medical-legal considerations and the prevailing local standard of care. However, a common list of quality-of-life categories includes:
- Pain scales
- Sleep scales
- Energy levels
- Depression levels
- Shortness of breath assessments
Functionality
Functionality is a separate issue from quality of life and refers to the patient’s ability to interact with the world and provide self-care in spite of the chronic disease. For example, one patient might report daily low back pain as 8 out of 10, but maintain a full time job; while another patient might report the same symptom number, but report difficulty with driving, light household chores, and maintaining employment.
The amount of information required for this section is not further specified, but is at the discretion of the physician, guided by medical-legal considerations and the prevailing local standard of care. However, a common list of categories includes:
- Activities of daily living
- Independent activities of daily living
- Effect of the disease on
- Employment
- Heavy lifting
- Light household chores
- Driving
- Ability to climb stairs
- Walking distance
- Time able to stand
- Time able to sit
Medications: Tolerance, Adherence, Reconciliation
Medications are a mainstay of chronic disease care, particularly for patients with moderate to severe disease severity. Medication adherence, tolerance, and possible adverse effects and interactions are responsible for many avoidable emergency visits and hospitalizations.
The patient’s self-reported medication adherence and tolerance to the medications should be documented. This section could include longer documentation of an HPI and related information to properly investigate a symptom the patient feels may be related to a medication. The amount of information required for this section is not further specified, but is at the discretion of the physician, guided by medical-legal considerations and the prevailing local standard of care.
Physical Examination
Documentation expectations are no different from those previously described. Only one physical exam section is required for the clinic visit (i.e. the physician does not have to document a separate physical exam for each issue addressed).
Lab/X-ray results
This section includes values obtained prior to the clinic visit or obtained as a point-of-care test on the same day. For visits in which multiple issues were addressed, only one lab/X-ray section is required (which does not create the assumption that labs should be included in each visit. No labs/x-rays is often appropriate).
Issues Addressed and Treatment Plan
This section is required for all clinic visits. For patients for whom multiple issues are addressed at one visit, only one treatment section is required. For most chronic disease treatment plans, the following should be documented:
- Brief description of the education provided to the patient about self-care, if indicated. Examples include:
- Daily weights for patients with heart failure, and what to do if the weight changes substantially
- Asthma self-care information given
- Diabetes treatment adjustments for sick days
- Medications refilled or prescribed that day.
- A master chronic medication list is expected to exist in a location separate from the daily progress notes.
- Other recommended tests or therapies, if any
- Recommended referrals, if any
PROCEDURES
Procedures performed in the clinic may be documented as separate notes or imbedded in another type of note. The note may contain the following elements:
- Name of procedure
- Indication
- This may be left off if the reason is self-evident. For example if the chief complaint is laceration, this does not need to be re-documented.
- Location
- Size of lesion, if applicable
- Anti-septic prep given prior to procedure, if indicated
- Other pertinent preparatory work, if indicated, such as removing gravel from a wound
- Anesthetic used, if pertinent
- Complications, if any
- Patient response, if pertinent