Auto-input Patient Information Into Notes
Auto-input Patient Information Into Notes
Is there a way to auto-input patient information into progress notes? Age, Medical Problems, Allergies, etc? I know how to do it for exam sheets, but we use progress notes for everything so we can copy and paste findings across the years and not "loose" them with each new exam sheet.
Re: Auto-input Patient Information Into Notes
Anyone from OD able to give some color commentary on how hard or not this might be to do?
Re: Auto-input Patient Information Into Notes
Everything you mentioned, age, problems, allergies, show in the Patient Info grid just to the left of the Progress Notes grid. The difficulty of auto-importing (and significantly cluttering) said information into notes seems superfluous. Maybe my definition of Progress Notes is different than yours? I'm referring to the Progress Notes grid within the Chart Module.
The best thing about a boolean is even if you are wrong, you are only off by a bit.
Jason Salmon
Open Dental Software
http://www.opendental.com
Jason Salmon
Open Dental Software
http://www.opendental.com
Re: Auto-input Patient Information Into Notes
I'm with you on the explanations. I agree it's not helpful for me as a provider to have it in the progress notes since I can just look at the patient info grid, but it's helpful to have it in the progress notes for third parties. I'm a pediatric dentist who works with Medicaid.
When you look at medical records from EPIC it does all of that kind of stuff. Yes, it clutters the note up, but it also legally protects the doctor because any malpractice attorney or state board investigator will tell you "if it wasn't written down in the note then it didn't happen."
For example, my clinical note says that medical history was updated in the chart, but I've had some pushback from medicaid about that wording because it doesn't specify what if anything has changed (asthma, medications, etc). If parents updated it on their forms which changed the patient grid and wrote into the progress notes, then that problem is solved.
Another use case would be the ability to have the notes populated with parent responses. We try and keep track of how often a parent is brushing their child's teeth in the notes each time. We use Flex forms to collect that information which changes the patient info grid, but we can't get it into the progress notes without manually typing. Double work. Add that up over about 10,000 appointments per year and suddenly there is opportunity for lots of time gain through efficiency.
Another use for us in a pediatric office. A person checks in and provides their relationship to the patient (usually parent, but maybe aunt/uncle, step-parent, etc) and writes their name down, that would auto populate into the note as well at the top. We currently have to ask so that we type the correct name and relationship. It's super helpful to know who we had the conversation with the day of the appointment so we make the effort, but it definitely is effort.
I could go on with different scenarios of what would be helpful to see in the note, but I think I've hopefully provided some reasons why it wouldn't be superfluous. The actual note is the legal document for us, not the patient grid. So having that ability to auto-input information into the note is helpful.
When you look at medical records from EPIC it does all of that kind of stuff. Yes, it clutters the note up, but it also legally protects the doctor because any malpractice attorney or state board investigator will tell you "if it wasn't written down in the note then it didn't happen."
For example, my clinical note says that medical history was updated in the chart, but I've had some pushback from medicaid about that wording because it doesn't specify what if anything has changed (asthma, medications, etc). If parents updated it on their forms which changed the patient grid and wrote into the progress notes, then that problem is solved.
Another use case would be the ability to have the notes populated with parent responses. We try and keep track of how often a parent is brushing their child's teeth in the notes each time. We use Flex forms to collect that information which changes the patient info grid, but we can't get it into the progress notes without manually typing. Double work. Add that up over about 10,000 appointments per year and suddenly there is opportunity for lots of time gain through efficiency.
Another use for us in a pediatric office. A person checks in and provides their relationship to the patient (usually parent, but maybe aunt/uncle, step-parent, etc) and writes their name down, that would auto populate into the note as well at the top. We currently have to ask so that we type the correct name and relationship. It's super helpful to know who we had the conversation with the day of the appointment so we make the effort, but it definitely is effort.
I could go on with different scenarios of what would be helpful to see in the note, but I think I've hopefully provided some reasons why it wouldn't be superfluous. The actual note is the legal document for us, not the patient grid. So having that ability to auto-input information into the note is helpful.
Re: Auto-input Patient Information Into Notes
Medicaid; Say no more.
This would be extremely difficult; You basically need a breakdown at an Audit Trail level of the entire patient encounter / appointment IMO. This would be a Feature Request that would need to be extremely detailed in regard to what you need in order to jump through the hoops being placed in front of you. Not only that, but whatever Open Dental implements for said Feature Request would need to be adhered to by Flex forms (either by using our API or by changing their software so that all parties involved are playing by the required Medicaid rules together).
This would be extremely difficult; You basically need a breakdown at an Audit Trail level of the entire patient encounter / appointment IMO. This would be a Feature Request that would need to be extremely detailed in regard to what you need in order to jump through the hoops being placed in front of you. Not only that, but whatever Open Dental implements for said Feature Request would need to be adhered to by Flex forms (either by using our API or by changing their software so that all parties involved are playing by the required Medicaid rules together).
The best thing about a boolean is even if you are wrong, you are only off by a bit.
Jason Salmon
Open Dental Software
http://www.opendental.com
Jason Salmon
Open Dental Software
http://www.opendental.com
Re: Auto-input Patient Information Into Notes
I thought it would be extremely difficult. I doubt it's worth the tens if not hundreds of thousands of dollars in coding time it would take to completely revamp the way notes are configured. I think the lowest hanging fruit would just allow some sort of option in autonotes to read the patient info grid and paste whatever is listed there for each category. Flex, Modento, Yapi, etc would then just have to make sure they used the appropriate APIs (that I think are already in place) for things like health history updates, allergies, etc.
Re: Auto-input Patient Information Into Notes
How are you providing this information Medicaid in the first place? What makes you want to put all this information into the Progress Notes in the first place? Are you printing the Progress Notes and sending that to them or something? E.g. It would be far easier to enhance something like the Print button to not only print the Progress Notes but to also include the Patient Information grid as well.
The best thing about a boolean is even if you are wrong, you are only off by a bit.
Jason Salmon
Open Dental Software
http://www.opendental.com
Jason Salmon
Open Dental Software
http://www.opendental.com
Re: Auto-input Patient Information Into Notes
Putting it into the note is mostly just for legal safety. I’m a little paranoid but that’s what you get when you come from a family (both parents, both siblings, and 2 close relatives) of attorneys.
Medicaid doesn’t ask for it unless we are audited. Fortunately we’ve never been audited directly, but we did get dragged into an audit of another office a few years back due to a mutual patient. Medicaid asks for everything during the audit. It took my wife almost an entire day. We had to send… Every form that we have that is unsigned. Every form that is signed by the patient. X-rays that are labeled with name and date. Charts and what the colors mean. Progress notes. Health history updates. For any abbreviation in our notes or com logs (like DO) we had to write out distal occlusal and send it as a “key” to decode it. No matter how easy it would be to understand (BP and HR are blood pressure and heart rate for example). That’s just what I remember but it was even more.
Medicaid doesn’t ask for it unless we are audited. Fortunately we’ve never been audited directly, but we did get dragged into an audit of another office a few years back due to a mutual patient. Medicaid asks for everything during the audit. It took my wife almost an entire day. We had to send… Every form that we have that is unsigned. Every form that is signed by the patient. X-rays that are labeled with name and date. Charts and what the colors mean. Progress notes. Health history updates. For any abbreviation in our notes or com logs (like DO) we had to write out distal occlusal and send it as a “key” to decode it. No matter how easy it would be to understand (BP and HR are blood pressure and heart rate for example). That’s just what I remember but it was even more.