I am reviewing previously entered CPPs when I see patients, and correcting earlier mistakes. I am now systematically entering CPPs from my alphabetical list of rostered patients; I am about 30% done. I see about 10% of my patients without any paper charts being pulled at all; we are still often pulling charts that have been marked as "EMR".
There are different ways to organize a CPP. The way I've organized mine is:
- current, ongoing health conditions (diabetes, asthma, hypertension etc). These are all coded in 3 digit ICD 9, for easy searchability
- allergies (drug, non drug); coded from the drug reference software
- social history (smoking, alcohol, marital status etc)
- family history; all coded in 3 digit ICD 9
- past medical history. This is free text, and thus not easily searchable, but easy to enter. It contains previous operations; previous limited medical problems (eg, gastritis); previous antibody results (rubella Ab, varicella status, hep A/B Ab); date of last previous screening tests (pap, mammo, DXA, FOB); date of last full check up
- procedures (structured), with date and result: gastroscopies, colonoscopies, hysterectomies, previous breast cancer. The last 3 are to help me with preventive audits, the gastroscopy is because I can never find it in the paper chart
- immunizations
- alerts
- labs (entered directly via a button in the electronic lab result, eg: pap, FOB, Hep B Ab, others). The free text Past Medical History area is only for old paps and FOBs. All new ones go in the CPP lab area.
- flowsheets
- Framingham cardiac risk score
- referrals (entered directly from the EMR referral)
I have been told that my templates can be put on the general server; I will ask Nightingale to transfer the preventive health templates, the sore throat score, the small smoking cessation template, and the Ottawa ankle and knee rules.
On Tuesday, we start scanning all the old charts. Happy Canada day, everyone!
Michelle
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