Dr. John Hickner, Editor and Chief of the Journal of Family Practice Discusses the Shortcomings of Many Medical Notes
In his recent editorial in the October edition of the Journal of Family Practice, Dr. John Hickner (MD, MSc) notes that many doctors fail to adequately document three portions of the medical note: history of present illness (HPI), assessment and plan.
"After reviewing many charts from several organizations, however,
I’m concerned that 3 important elements of documentation are getting
short shrift in our increasingly computerized and regulated environment:
the history of present illness, the assessment, and the plan."
Dr. Hickner was kind enough to chat with us at the American Academy of Family Practice Conference that ended yesterday. Like us, he wants medical notes to tell the story underlying the patient's present visit; not just a checklist of symptoms. The emphasis of quantity over quality by the healthcare system and electronic medical records (EMRs) has eroded the quality of the HPI. During our conversation at the conference, he acknowledged that scribes may have a role in solving the dearth of quality documentation by some medical doctors. You can read his full article on the Journal of Family Practice website. And again, it was a pleasure chatting with Dr. Hickner at the conference.
Medical Scribe Training Systems will be at the American Academy of Family Practice (AAFP) in Washington D.C. Thursday October 23 through Saturday October 25. This is your chance to ask us any questions about the logistics of having and training a scribe. We will be located in the Technology Pavilion in between eClinicalWorks, e-MD and Cerner. Come check us out!
We recently updated and upgraded our primary care scribe training manual! The improvements include a new chapter titled "Management of Chronic Diseases." It details the monitoring, management and medications used to treat the most commonly encountered chronic diseases in family practice and internal medicine including type II diabetes, hypertension, hyperlipidemia, and hypothyroidism. You can check out the new edition on Amazon.