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Progress notes

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This section explains how to create, manage, and utilize progress notes within 4Geeks Health. Progress notes are a crucial part of the patient’s medical record, documenting the patient’s status, the care provided, and the provider’s observations, assessments, and plans.

What are Progress Notes?

Progress notes are chronological records of a patient’s clinical status and care during each encounter with a healthcare provider. They serve multiple purposes:

  • Documentation: They provide a legal and accurate record of the patient’s condition, treatment, and progress.
  • Communication: They facilitate communication and coordination of care among different healthcare providers.
  • Clinical Decision-Making: They inform clinical decision-making by providing a history of the patient’s response to treatment.
  • Billing and Reimbursement: They support billing and reimbursement claims.

Accessing Progress Notes

You can access progress notes in several ways:

  1. From a Patient Record:

    • Navigate to the patient’s medical record.
    • Look for a section or tab labeled “Progress Notes,” “Notes,” “Encounters,” or similar.

  2. From an Outpatient Visit or Inpatient Encounter:

    • Open the specific visit or encounter record.
    • Progress notes are typically a central component of the encounter documentation.

  3. From an Appointment (if linked):

    • If a progress note is associated with a specific appointment, there may be a link to the note from the appointment details.

Creating a Progress Note

The method for creating a progress note depends on the context:

  • Open the Outpatient Visit or Inpatient Encounter record.
  • The progress note section may be automatically displayed or accessible via a tab or button.
  • Start typing or selecting options within the designated fields.

2. Standalone Progress Note (Less Common)

  • Navigate to the “Progress Notes” section within the patient’s record.
  • Click a “New Progress Note,” “Add Note,” or similar button.
  • You may need to manually select the patient and enter the date and time. This method is less common because it’s best practice to link notes to specific encounters.

Progress Note Structure and Content

Progress notes often follow a structured format, such as SOAP (Subjective, Objective, Assessment, Plan), but the specific format and required fields may vary depending on your organization’s configuration and the type of encounter.

Common Elements:

  • Date and Time *: The date and time the note was written (or the date and time of the encounter). Mandatory.
  • Author/Provider *: The healthcare provider who wrote the note. This may be automatically populated. Mandatory.
  • Patient *: The patient the note pertains to. This is usually pre-selected if you are creating the note from the patient record or encounter. Mandatory.
  • Encounter Type: (e.g., Office Visit, Hospital Follow-up, Telehealth Consultation).
  • Chief Complaint: The patient’s primary reason for seeking care.
  • History of Present Illness (HPI): A detailed description of the patient’s current symptoms.
  • Review of Systems (ROS): A systematic inquiry about symptoms in different body systems.
  • Physical Examination: Documentation of the provider’s physical examination findings.
  • Vitals Signs: Patient’s vitals signs record.

SOAP Format:

  • Subjective (S): Information provided by the patient or their caregiver. This includes:

    • Chief Complaint
    • History of Present Illness (HPI)
    • Past Medical History (relevant to the current problem)
    • Social History (relevant to the current problem)
    • Family History (relevant to the current problem)
    • Review of Systems (ROS)
    • Patient’s perception of their progress

  • Objective (O): Observable and measurable findings. This includes:

    • Physical Examination findings
    • Vital Signs
    • Laboratory Results
    • Imaging Results
    • Other diagnostic test results

  • Assessment (A): The provider’s synthesis of the subjective and objective information, leading to a diagnosis or differential diagnosis (list of possible diagnoses).

  • Plan (P): The provider’s plan for managing the patient’s condition. This may include:

    • Medication Orders
    • Lab Orders
    • Procedure Orders
    • Therapy Orders
    • Referrals
    • Patient Education
    • Follow-up instructions

Free Text vs. Structured Fields:

  • Some systems use free-text fields for progress notes, allowing providers to type narrative descriptions.
  • Other systems use structured fields with dropdown menus, checkboxes, and pre-defined templates to guide documentation and ensure consistency. This can also facilitate data analysis and reporting.
  • A combination of free text and structured fields is often the most effective approach.

Completing and Signing a Progress Note

  1. Thorough Documentation: Ensure all relevant information is documented accurately and completely.
  2. Review: Carefully review the note for any errors or omissions.
  3. Sign: The provider must electronically sign the progress note to attest to its accuracy and completeness. This may involve:
    • Typing their name and credentials.
    • Using a digital signature.
    • Clicking a “Sign” or “Finalize” button.
  4. Locking: Once signed, the progress note is usually locked to prevent further modification (except perhaps through an addendum process).

Managing Progress Notes

  • View: You can view past progress notes from the patient’s record or the encounter record.
  • Print: You can typically print progress notes.
  • Addendum: If you need to correct an error or add information to a signed progress note, you should create an addendum. The addendum should clearly indicate:
    • The date and time of the addendum.
    • The original note being amended.
    • The reason for the addendum.
    • The new or corrected information.
    • The addendum must be signed by the provider.
    • Never delete or alter the original signed note.

Important Considerations

  • Legibility: Ensure that progress notes are legible (especially if handwritten or using free-text fields).
  • Accuracy: Document information accurately and objectively.
  • Completeness: Include all relevant information, but avoid unnecessary details.
  • Timeliness: Write progress notes promptly after the patient encounter.
  • Confidentiality: Maintain strict patient confidentiality.
  • Compliance: Adhere to all relevant regulations and your organization’s policies regarding documentation.
  • Training: Provide proper training for staff.

This documentation provides a comprehensive overview of managing progress notes in 4Geeks Health. Remember to adapt any specific field names, formatting requirements, or steps to match your organization’s customized configuration and documentation standards.