Dream Factory by TruBridge Ideas Portal
Our providers consistently include diagnoses in documentation, however, they balk when asked to also document within the Problem List. Yes, I know they could go to the Problem List or PDC first and then information could pull into Notes, however, this is not providers' preferred workflow. It would be hugely beneficial if they could create problems directly from the Note.
Yes! Providers are required to document Diagnoses within their notes. If these Diagnoses would drive the Problem List - we would get a lot more buy-in. We have surgeons who refuse to use Notes and instead use Surgical CAPD because their diagnoses are coded as they enter them and there is no extra work on their part.
Just got out of a physicians meeting. This was a complaint. The NOTE needs to drive the update to the EHR applications. Not the applications driving the NOTE. Problem List is a great example. Physicians have to go to the traditional application or console. Enter data, flag treated this visit, add comments, whatever. Then make sure the Problem List is up to date. Then create the NOTE and insert the data. If there is a issue, they have to leave the document, access the application, make corrections, additions, whatever, then reaccess the NOTE. Remove this incorrect information and reinsert the new. Many many steps.