Dream Factory by TruBridge Ideas Portal
Nurses are generally tasked with documenting a patient's Health History. When adding 'problems' they're forced to pick from the ICD10 listing. Their understanding of the Health History is to get a general documentation for a provider's review - not to provide a diagnosis. It takes a while and ends up having a nurse randomly pick a dx which is often incorrect. For example, if a patient has Hypertension...there are dozens of codes and options and if there is a generic - it doesn't pull to the top. Need an easier way to enter these histories in without having to "be a coder."
Thank you for you input @Guest . We have been having discussions internally about Medical History and how we can make this a better workflow with the Problem Management card/Problem List. The go forward plan is to update the Problem management card with features from the Problem List and then that will be the only way to enter problems.
Along with this - I would really like to see health history and problem list combined more seamlessly. It is double work for a nurse to enter health history and provider to enter problem list. I do realize there is a check box on problem list to include in medical history. There is also an extra click on the medical history entry and you cannot see what you already entered when adding a new item. In problem list, you can view your list. Also, problem list is the only one that can be filtered into Notes. So we actually have our nurses entering these in the problem list, and checking the box to include in medical history because it functions better AND providers the doc with a better list within their NOTE. Also, the problem list is what is sent in the CCDAs and to the CDC for ECR. So it needs to be updated and accurate which is best done by the nurse. We do have our providers review it to mark items as resolved, acute, chronic, etc. but sometimes they forget and understandably so. I don't understand why TruBridge continues to recommend Health History for nurses and Problem List for physicians. Why not just make it all a shared list that pulls into the note?