Documenting a visit for a patient with cold symptoms can sometimes take longer than the visit itself. To simplify this process, our practice implemented a problem-specific encounter form for upper respiratory infection (URI) symptoms. It provides the documentation necessary for us to meet the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) guidelines at minimal cost or effort.

How it works

Patients who indicate at registration that they have URI symptoms are given the encounter form folded in half and are asked to complete the patient questionnaire side. This includes questions about pain, which the JCAHO requires us to regard as a fifth vital sign, and asks whether the patient needs a work note or prescription refills, which can help the physician pace the visit. (View and download the form below.)

The physician then reviews this information with the patient and documents the chief complaint and a brief history of present illness, consistent with coding guidelines for a level-III established patient visit. The exam, diagnosis and plan portions are completed primarily through the use of check-off boxes, which improve legibility. The documentation is complete by the end of the visit, eliminating the need for dictation in most cases.

Patients generally do not object to filling out the form, although we do get an occasional complaint. Our secretaries and physicians respond by encouraging patient participation in the process and stressing the importance of the information gathered. This message is reinforced when the physician actually uses the form during the visit to review the patient’s information. If a patient does not complete the form, we do not make an issue of it and find other ways of gathering the needed information. Our nursing staff helps those patients with sight or reading difficulties to complete the form.

Results

Physician acceptance of the URI encounter form was nearly instantaneous. Documentation is now simple and efficient, and a URI visit can easily be added to a full schedule. In addition, because the form standardizes the questions we ask our URI patients, the care we provide is more thorough and consistent.