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Introduction: Writing in the Health Professions
Published in Michael J. Madson, Teaching Writing in the Health Professions, 2021
Surveying medical schools in the United States, Yanoff and Burg4 cataloged the genres considered the most important to teach. At the top of the list were write-ups of patient histories and physician examinations, progress notes and discharge summaries, peer-reviewed publications, and grant proposals. Other important genres included letters to referring doctors, outpatient records, consultation reports, and admitting notes.
History taking and examination
Published in Peter Kopelman, Dame Jane Dacre, Handbook of Clinical Skills, 2019
Peter Kopelman, Dame Jane Dacre
Electronic medical records provide a structure for documenting a patient’s progress once a presumptive diagnosis has been made. Such records identify presenting problems and list them in automatically generated correspondence. The inclusion of both active and inactive problems is most helpful because it will alert a doctor to the entirety of past problems at each consultation with the patient. During a hospital admission, it is useful to follow the patient’s progress by continually entering progress notes in a similarly structured fashion, addressing each of the patient’s active problems in turn. These should be clearly written, signed and dated.
The Management of a Private Practice in Educational Therapy
Published in Maxine Ficksman, Jane Utley Adelizzi, The Clinical Practice of Educational Therapy, 2017
A successful practice owes much to careful planning immediately after the session. It is essential to keep progress notes, which are referred to as clinical notes by some professionals and SOAP notes by others (Subjective, Objective, Assessment, and Plan) in a timely and systematic manner. In my own practice, I initially kept what I referred to as progress notes mainly to track the specifics of the session, so that I could refer back to the folder in order to determine what was done and when. However, as I gained experience, my notes took on a more important and deeper function. Instead of being a mere record of what happened during a session, the note writing itself became a vehicle for reflection and deeper understanding of the dynamic of intervention. I found that progress or clinical note writing provided insights and perspective into the nature of the client and the intervention that might not have occurred if I had not spent the time on the notes. The act of writing helped me shape the ‘story’ of the client as I went beyond the immediate details to sense the larger trajectory of our work together. Sometimes there is an “Aha” so dramatic that I get on the phone immediately (depending upon how late it is) to share an insight with a parent.
Impact of treatment-related discussions on healthcare resource use and costs among patients with severe mental illness
Published in Current Medical Research and Opinion, 2021
Felicia Forma, Eleena Koep, John White, Angela Belland, Heidi Waters, Carolyn Martin
In addition, the data on compliance communication included in this analysis was only as good as the quality of the medical chart from which it was abstracted. The medical records included in this study represented a mix of hand-written progress notes as well as standard fields printed from electronic medical record applications. The results may have been skewed by the inclusion of standard electronic medical record text such as “take medications as directed,” which may not represent oral communication of treatment adherence/compliance. Furthermore, it is possible that adherence/compliance-related discussions took place but were not recorded in a manner detectable by the methods used to identify them in charts. Nevertheless, failure to include these data may have alternatively biased the results and not accurately represented the “real-world” treatment experience. This balance illustrates the challenges facing not only scientific investigators, but also patients, clinicians, and other stakeholders as the importance of matching patients with the most efficacious treatment is an ever-increasing component of service delivery.
Understanding the moral economics of occupational engagement
Published in Journal of Occupational Science, 2020
Nikhil Tomar, Antoine L. Bailliard
Finally, Sharon (staff) elaborated on the influence of these texts in not just maintaining a clubhouse but also the kind of care that is decided by larger institutions for adults with SMI. Let’s go back to the notes. This is the way the system has developed. It’s largely a medically based model and that’s how Medicaid is framed as medically necessary. When you start getting into it, I think that we fail to recognize that if somebody needs physical rehab, that clearly seems to be something that is supported and necessary but psychiatric rehab is not so much. The type of work that is needed for someone with SMI is very different than your physical rehab.Sharon highlighted that psychosocial rehabilitation is sometimes not viewed as necessary by larger institutions, which affects billing rates. Clubhouse Journey has been in multiple discussions with policy stakeholders to increase its billing rate to a similar rate as Clubhouse Odyssey (around $15/hour), which is in a different county. The texts are submitted to higher institutions for reimbursement, such as managed care organizations, that may evaluate psychiatric recovery as similar to physical recovery. For example, staff always expressed concern that psychiatric recovery is not always evident within a week, yet they have to submit progress notes on a weekly basis. Thus, documentation of occupational engagement via texts helps maintain not just a clubhouse but also the larger institutions that dictate how a clubhouse functions.
Optimizing the electronic medical record to improve patient care and conduct quality improvement initiatives in a concussion specialty clinic
Published in Brain Injury, 2020
Kelly Claire Simon, Nicole Reams, Erik Beltran, Charles Wang, Bryce Hadsell, Darryck Maurer, Laura Hillman, Samuel Tideman, Lisette Garduno, Steven Meyers, Roberta Frigerio, Demetrius M. Maraganore
The concussion clinic at NorthShore University HealthSystem includes three specialized neurologists with initial visit appointment lengths of 60 min. For the first three months of developing this project, the neurologists met every 2 weeks to determine toolkit content to support Best Practices in treating patients following an mTBI. At initial meetings, we consulted the AAN practice guidelines and quality measures, CDC guidelines, and the National Institute of Neurological Disorders and Stroke. We next designed a workflow that included a medical assistant and neurologist, to accomplish the visit activities without extending the face to face time with the neurologist. We envisioned standard workflows and progress notes (the order and layout in which the content would write). We limited the medical assistant and/or nurse assessments to 15 min each and the neurologist assessment to 60 min. This process of content building required 3 months.