progress notes

adrienne.bakeradrienne.baker
edited May 2016 in CDI Talk Archive
Hi all,
We are wanting to put together a template for progress notes that our Hospitalist group can use for easier documentation. Does anyone currently use something like this? We are a hybrid chart at this point so our progress notes are still paper in the chart. Thanks for any ideas that come our way!

Adrienne Younger, RN CCDS

Comments

  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    Arlene
    We implemented templates over a year ago (prior to our current situation of an all electronic med record/pDoc). What I learned is, the best thing to do is MEET with the Hospitalists and get their needs and concerns first. We built a progress note template and had to completely re-do it because it wasn’t what the majority of them wanted.
    You can build a skeleton and send it to them and ask for opinions, but it is difficult because invariably not everyone will agree. You end up going with "majority rules". But again, truly, if you have a physician champion-or another doc that is well respected by others-start there and get them involved because the transition then, is so much easier if you have a doctor backing up a project like that!

    Juli Bovard RN CDS
    Rapid City Regional Hospital/Regional Health
    Rapid City, Sd

  • kshumpertkshumpert
    edited May 2016
    Our hospitalists have a paper template that they use. One of our oncology NPs developed it and the hospitalists have been using it ever since. I would be willing to share if you are interested.

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8152

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela



  • Unknown
    edited May 2016
    Good morning Kathy - please share! I bet you have a bunch of us intrigued... Linnea


    Linnea Thennes, RN, BS, CCDS
    Supervisor, Clinical Documentation Improvement
    Centegra Health System
    815. 759-8193
    lthennes@centegra.com



  • adrienne.bakeradrienne.baker
    edited May 2016
    Thanks Kathy, that would be great!!

    My email is Adrienne.Younger@BSAHS.org

  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    I would love to see your template also!
    Thanks (in advance)!

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603
    Pager: 98-1001



  • kshumpertkshumpert
    Sure thing! I will get a copy, scan it in and post it:)

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8152

    When something can be read without effort, great effort has gone into its writing.
  • cstukenbergcstukenberg
    edited May 2016
    Yes. I have developed one working with our hospitalist and coding staff.

  • bosankorbosankor
    edited May 2016
    I would love a copy as well! Thank you for sharing!

    Roberta Bosanko-Cera MS, CCS-P, CPMA, CPC-P, CEMC
    AHIMA ICD-10-CM/PCS Ambassador & Training Instructor
    Director, Finance ICD-10
    Hospital For Special Surgery
    535 E 70th Street
    New York, NY 10021
    bosankor@hss.edu
    212-774-2906 Office

  • mdomineseymdominesey
    edited May 2016
    Please send me a copy as well. This exact effort is on my list of projects (as a stopgap until we implement Epic in 2013).

    Mark
    mdominesey@sibley.org

    Mark N. Dominesey, RN, BSN, MBA, CCDS
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital



  • kshumpertkshumpert
    Please see attached progress note. This is a scanned in image. I could only get a paper copy today. The issues that I have had with it have been when one of our NPs works. She is a writer indeed and has written down well into the margins. We have corrected that by using a second page strictly for the impression and plan. Have a great weekend everybody!

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8152

    When something can be read without effort, great effort has gone into its writing.
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Did anyone else have problems pulling it up? It is blank with heading of "Hospitalist Progress note-Notepad". Kathy could you please email it directly to me? chutchinson@saintfrancis.com
    Thanks!

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603
    Pager: 98-1001



  • dvitalone1dvitalone1
    edited May 2016
    Yes, me too


    Dawn M. Vitalone, RN

  • Unknown
    edited May 2016
    Thank you Claudine - I thought it was just me! Is there some secret to opening this note format?

  • adrienne.bakeradrienne.baker
    edited May 2016
    Yes all I got was a blank attachement?

  • ddraizeddraize
    edited May 2016
    I couldn't open either

    Diane Draize RN, CPUR,CCDS
    Clinical Documentation Specialist

    Ministry Door County Medical Center
    diane.draize@ministryhealth.org
    920-743-5566 ex 3143

    We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do

  • judithbatesjudithbates
    edited May 2016
    blank for me too...

  • sbeattysbeatty
    Ditto here. I'd also like to see what you've developed.
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