How do I decide the best way to document a phone call?
ANSWER: Besides the standard "SOAP encounter", EyeCHARTS allows several different methods to document non-exam events such as telephone calls, billing issues, and reminders. The grid below explains the possibilities:
Sticky Note: Resembling the ubiquitous sticky notes that clutter most desks, this is an electronic version for brief, non-clinical messages. Examples might include: a note to the doctor that the patient is running late, that a patient seems annoyed about waiting so long, or a reminder that results need reviewed before finalizing the record. Both the front desk staff and the clinical staff can make use of sticky notes. The sticky note is temporary (deleted automatically when the chart is re-filed) and is for internal use only (not appropriate for clinical information).
Billing Note: For use mostly by front desk staff, the billing note allows for brief documentation of billing issues, disputes, insurance discrepancies and collection problems. Short transcripts of telephone conversations about billing issues would be appropriate as well. The billing note is part of the permanent chart (saved each time it is modified) and is for internal use only (not printed as part of the patients chart record).
Reminder E-Message: A reminder E-message is very similar in format to an email message. Generated either by the clinical staff or the front desk staff, the message is timed to appear at some specified future date. Examples would include reminders to have a patient come in for visual field testing, to notify the doctor to review a consultation report due back, or a reminder to schedule an uncompleted contact lens follow-up appointment. The reminder message is temporary (in the sense that it is visible only during a discreet time period), but it is part of the legal chart (once the final disposition is indicated, the reminder message text is appended to the general chart notes).
Chart Note: An integral companion to the encounter documentation, the chart note is for additional clinical information that falls outside of the scope of the regular encounter record. For example, telephone conversations regarding clinical data (e.g. medication refills, contact lens complaints, etc) would be described in the time-stamped chart note. Other uses include brief discussions of lab results, consultation visits, record review, and notation of missed patient appointments (and the actions taken). The chart note is legal record that becomes part of the permanent chart (requires signing by an authorized signer).
Any of the note methods are available from the Pulled Charts list. Right-click on the patient name and select “Message Manager” to bring up the appropriate choices.