I have a “To Do” list of EHR requests, as well as a “To Do” list for all the stuff that needs to be done at home (and both lists can get quite long –with approximately 1200 EHR users and three busy kids!). I’m sure that you also have similar lists.
So, when it comes time to maintain more lists (problem lists, allergy lists, medication lists, etc), I can imagine your response is less than enthusiastic. But lists tend to be generated for a purpose. I know without mine, I would forget many of the things I put on them (and my kids would probably go hungry because I would forget to pay their lunch money). Lists in the EHR, obviously, help us keep up with our patients’ current diagnoses, medical histories, medications, and allergies. With the patient volume many of our clinics handle, keeping lists is essential for providing quality patient care.
That’s why maintaining and reconciling lists is part of the core objectives for Meaningful Use.
Maintain an up-to-date problem list of current and active diagnoses.
Maintain active medication list.
Maintain active medication allergy list.
According to the TennCare website, the up-to-date problem list measure requires that “MORE THAN 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient as structured data.” So what exactly does this mean? Simply put, active problems need to be entered on the Clinical Desktop (i.e. electronic chart) for your patients, and if by chance they have no active problems? That needs to be recorded as well (For our Allscripst users, ‘No Active Problems’ should be a quick list item in the ACI). And take note of the word CURRENT. If the patient comes back to see you for a follow up or office visit, and the rash associated with poison ivy from the last visit is still listed as an active problem, then resolve it. If the patient is pregnant—and delivers— then resolve it.
Additionally, “more than 80 percent of all unique patients seen by the EP must have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.” The same requirement is true for allergies.
The Allscripts system makes it easy enough to reconcile these lists, but when you click on Reconcile, remember that you are stamping the list as up-to-date. You must take the time to review the lists with the patient and make sure that all medications and allergies are accurate. Otherwise, when you click on reconcile and you have not truly “reconciled" it, you are falsely documenting in the chart. We have seen time and time again where duplicate meds and expired meds are still on a list that has been stamped as reconciled.
As I mentioned in my last post, clinics must work on office workflows to ensure that someone is going over these lists with the patient at each visit, whether it’s the nurse or the provider. We encourage spot checking daily schedules and lists to ensure accuracy. And if you can’t remember this recommendation, how about adding it to your “To-Do” list?
So, when it comes time to maintain more lists (problem lists, allergy lists, medication lists, etc), I can imagine your response is less than enthusiastic. But lists tend to be generated for a purpose. I know without mine, I would forget many of the things I put on them (and my kids would probably go hungry because I would forget to pay their lunch money). Lists in the EHR, obviously, help us keep up with our patients’ current diagnoses, medical histories, medications, and allergies. With the patient volume many of our clinics handle, keeping lists is essential for providing quality patient care.
That’s why maintaining and reconciling lists is part of the core objectives for Meaningful Use.
Maintain an up-to-date problem list of current and active diagnoses.
Maintain active medication list.
Maintain active medication allergy list.
According to the TennCare website, the up-to-date problem list measure requires that “MORE THAN 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient as structured data.” So what exactly does this mean? Simply put, active problems need to be entered on the Clinical Desktop (i.e. electronic chart) for your patients, and if by chance they have no active problems? That needs to be recorded as well (For our Allscripst users, ‘No Active Problems’ should be a quick list item in the ACI). And take note of the word CURRENT. If the patient comes back to see you for a follow up or office visit, and the rash associated with poison ivy from the last visit is still listed as an active problem, then resolve it. If the patient is pregnant—and delivers— then resolve it.
Additionally, “more than 80 percent of all unique patients seen by the EP must have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.” The same requirement is true for allergies.
The Allscripts system makes it easy enough to reconcile these lists, but when you click on Reconcile, remember that you are stamping the list as up-to-date. You must take the time to review the lists with the patient and make sure that all medications and allergies are accurate. Otherwise, when you click on reconcile and you have not truly “reconciled" it, you are falsely documenting in the chart. We have seen time and time again where duplicate meds and expired meds are still on a list that has been stamped as reconciled.
As I mentioned in my last post, clinics must work on office workflows to ensure that someone is going over these lists with the patient at each visit, whether it’s the nurse or the provider. We encourage spot checking daily schedules and lists to ensure accuracy. And if you can’t remember this recommendation, how about adding it to your “To-Do” list?
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